Part 42

Symptoms in Solipeds. These may vary much in different cases but the leading characteristics, as seen in the dog, are prominent also in the soliped. There is marked restlessness, trembling, and extraordinary hyperæsthesia, as seen in starting at sounds, sudden flashes of light or other causes of disturbance. The ears are held erect and watchful for sounds; the eyes are red and mostly vigilant with at times pupillary dilatation and flashing. The sight of a dog rouses him instantly to attack it with teeth and heels. A stranger is liable to be similarly treated though the horse is still docile and kind to his keeper. There may be itching of the skin and above all of the seat of the bite. During a paroxysm the movements are usually violent, dangerous and even mischievous. There is constant restless movement, pawing, kicking the ground, the stall or attendants, lying down, rolling, rising, straining to urinate, or defecate, eversion of the rectum, shaking the head, muffled neighing, sniffing, snorting, everting of the upper lip, grinding of the teeth, or biting. In the absence of such paroxysms deglutition may be difficult, and the appetite depraved, the patient preferring earth or manure to the natural food. With spasms or paralysis of the pharynx, the food may be returned through the nose. In some cases a stiffness or impaired control of the limbs has suggested inflammation of the feet. In the uncastrated male and female generative excitement is the rule, the protrusion and erection of the penis, the swelling and rigidity of the clitoris, with frequent straining to pass water, the whinnying of the animal for its mate; attempts at copulation and even ejection of semen may be observed. The seat of the bite may be red, angry and itchy, so that the horse rubs, nibbles or gnaws it, often breaking it open anew. There is usually ardent thirst, and no dread of water, even when swallowing is difficult or impossible.

During a violent paroxysm the horse often bites the halter, blanket, manger, rack or stall, seizes the adjoining horse with his teeth, or gnaws, or tears strips of skin from his own shoulder, breast or limbs. In the same way he uses his feet with the most evident purpose of injuring man or beast that may approach him, or he breaks down his stall.

Even at an early stage there may be spasmodic movements of the eyes, face or body, and later there appear signs of paresis, often commencing in a hind limb and extending to paraplegia and general paralysis. Sometimes paralysis begins in the muscles adjoining the seat of the bite. The temperature, at first normal, may rise to 104° F. in the advanced stages, breathing and pulse are greatly accelerated, and the skin may be bathed in perspiration. Spasms are not entirely superseded by paralysis, and death often takes place during a convulsion, from the fourth to the sixth day. In apoplexy death may ensue in one day.

Cases in which paralysis is not preceded by a furious stage are not uncommon in horses.

Symptoms in Cattle. Cattle are frequent victims of rabies, which assumes mostly the furious type, yet in certain outbreaks the paralytic or lethargic form predominates. There is first a strange irritability and restlessness, very unlike the habitual quiet disposition of the animal. The head is raised, the ears alert, the eyes prominent, red, fixed, with occasionally widely dilated pupils and brilliant flashes from the tapetum lucidum. Sometimes they roll or squint. They may appear wild and ferocious or dull and hopeless. Loud and terrified bellowing is not uncommon, switching of the tail, drivelling of saliva, and exceptionally there are attempts to bite. More commonly the natural weapons of offense are employed, the animal kicks, stamps, paws and, above all, tries to gore man or beast, but especially any dog which may appear. They even make such attacks on purely imaginary beings and without any real, tangible enemy present. The bull, cow or heifer present the usual signs of genital orgasm. Appetite is lost or depraved and rumination arrested. Pharyngeal spasms or paralysis is not uncommon, and signs of colic with frequent defecation may be seen. Violent paroxysms are easily roused by the sight of a small animal and especially of a dog. In these attacks the animal may break his horns or teeth or otherwise injure himself. Sometimes the infection wound becomes irritable, itchy and red or even abraded and raw by licking.

The animal becomes rapidly exhausted and even emaciated by the violence of the paroxysms, and paresis sets in with dragging movements of the hind limbs, which advance to paraplegia and general paralysis. Rolling of the eyes, squinting and pupillar dilatation may be present. Death usually takes place from the fourth to the sixth day.

The purely paralytic rabies is not uncommon in cattle. There may be persistent yawning or other sign of nervous exhaustion or depression, halting on one or more limbs, usually behind, which advances to complete paralysis. In other cases the symptoms are those of mental dulness, and profound lethargy with gradually advancing emaciation. In paretic and paralytic cases the characteristic paroxysms on presentation of a dog may be absent.

Ladague claims to have seen intermittent cases with an interval of 27 and even 36 days.

Symptoms in Sheep and Goat. In these there is the same regular succession of symptoms through intense hyperæsthesia and excitability, fury and genital excitement to the terminal paralysis, or the palsy may set in early without premonitory violence. Among the marked features have been noticed, a change of expression, the pupils dilate, eyes flash, they lick or mount their fellows, they lick or rub the bitten part, snort, stamp or scrape with the fore feet, setting themselves in the attitude of attack, they may butt other sheep, fowls, and other animals, above all dogs, or they may deliver the attack in the air only, at some phantom enemy. They may bleat hoarsely or brokenly, grind the teeth, or work the jaws with the formation of froth about the lips. Galtier says they may even attempt to bite. Sooner or later weakness of the limbs, muscular incoördination, swaying and staggering bespeak enervation, the sheep lies constantly, and if raised stands with unsteady semi-flexed limbs, has trembling or convulsions and dies paralytic in from two to five days. Death has been delayed till the twelfth day (goat) or thirteenth (sheep). In some cases paralysis has been present from the start, the subject lying prostrate from the first.

Rabies in the Camel and Deer. In Algiers camels are often times bitten by rabid dogs and contract the disease showing both furious and paralytic symptoms. They are especially dangerous because of their propensity to bite, and to scatter the virulent product by sneezing.

In England rabies has prevailed extensively in parks of deer, which shut inside high walls have been bitten remorselessly by rabid dogs that had gained admittance. The symptoms of hyperæsthesia and paralysis followed the same general course as in other animals.

Symptoms in Swine. Rabid pigs are usually very restless, excitable and sensitive to all causes of disturbance. They will hide under the litter in the darkest corner but soon start without apparent cause, turn around and lie down again, or they bound up with grunt or scream and rush off as if pursued, push or leap against the wall, stand with ears pricked as if listening, and start violently at any noise or a flash from a lantern, trembling, squealing, or having muscular jerking. The eyes are at times fixed, or may roll, squint or flash from pupillary dilatation. The voice is hoarse, deglutition difficult, there is frequent clenching of the jaws, or grinding of the teeth, and frothing around the mouth. The victim may tear with his teeth the boards of his pen, or gnaw pieces of wood, he may swallow wood, pebbles or earth, and plunge his face in water or other liquid without fear or apparent dread or dislike. The disposition to bite may be viciously shown, and he may strike dangerously with his tusks, while in other cases it may be entirely absent. Peuch quotes cases in which no paroxysm was aroused by the sight of a dog, and others in which the pig would rise and grunt without showing any desire to bite.

Sows will sometimes bite or devour their offspring during a paroxysm, yet nurse and care for the survivors during the intervals.

Emaciation, weakness, exhaustion, lethargy and paralysis appear early, the victim remains down, or, if raised, moves weakly and unsteadily and no longer pays attention to noises nor blows. Death may ensue from the first to the sixth day.

Symptoms in Rabbits. Experimental cases in rabbits are now very common and usually assume the paralytic or lethargic type, there is weakness in the hind parts, advancing in a few hours to paraplegia, the fore limbs may be used for a time while the hind are flaccid and dragged behind, or the animal lies on the sternum and belly with the head sunken and resting on the feet, or he lies extended on his side, in a state of insensibility. In the early stages he may still masticate, with froth collecting on the lips, but there is difficulty in swallowing. If a foot is pinched it is drawn up often with a cry. The bowels are torpid though a few small, round, hard pellets are sometimes passed or a little urine. Incubation is shorter than in the dog, and the virus retains this habit when inoculated on other animals.

In the experimental cases in the Anti-rabic Institute in St. Petersburg, Helman found that the rabbits inoculated with virus from dogs having furious rabies, contracted furious rabies, while those inoculated from the less furious type of street rabies had the disease in the dumb form.

Symptoms in the Guinea-pig. In this animal as in the rabbit the disease has been mainly seen in the experimental form, and has assumed the paralytic type. It trembles, moves stiffly or weakly, lies most of its time and passes rapidly into paralysis. There is usually no tendency to bite, yet Peuch in a case of intraocular inoculation from a rabid cat observed the most violent excitement, loud hoarse screaming, bounding in different directions, biting of the wires of the cage, and other manifestations of violent rabies. In both forms there are liable to be convulsive movements of the jaws, accumulation of frothy saliva, and a free discharge of urine.

Symptoms in Birds. Chickens bitten by mad dogs have been seen to prove restless, erecting the feathers and moving aggressively toward man or dog or phantoms of their imagination and attacking with bill or spurs or both. This, however, rapidly advances to paralysis and death. In cases due to intracranial inoculation on the other hand, somnolence, lethargy, or coma appeared early, and was quickly followed by paralysis. This affects especially the legs and neck. Recoveries are common and the animal is thereafter immune. Subsidence, with complete intermission of symptoms, is more common than in rabbits, the disease reappearing later, and perhaps finally ending in recovery.

Symptoms in Wild Carnivora. The rabid wolf, fox, jackal, hyena, coyote, ferret, polecat and skunk lose their fear of man, and approach and attack him either in field, village or city. The disease has its furious and paralytic stages as in the dog, and the animals attack according to their nature, wolves being dangerous from flying at the face and throat, and skunks from stealing up and biting without warning.

Symptoms in Man. After the period of incubation prodromata may be present, or there may be suddenly and without any premonition, violent spasms of the pharynx and inability to swallow. The premonitory symptoms when present consist in irritability of the cicatrix which becomes red or blue, swollen, itchy or pricking, and an aura or shooting pain may extend from this toward the heart. There is anxiety, sighing, tremor, restlessness impelling to frequent change of place, insomnia, disagreeable or painful dreams, weariness, and gloomy forebodings. The face is pale and drawn, and the eyes wander or have a look of apprehension. There is some fever and often marked thirst, and the attempt to swallow rouses slight spasm or a sensation of tightness in the throat. The fauces, pharynx and eyes are congested, reddened and it may be swollen. Pulse and respiration are both quickened, the inspiration being often prolonged and sighing, and the expiration sobbing. At first the intellect is unimpaired; there is no illusion nor hallucination.

In cases in which premonitory symptoms are lacking, violent spasms of the throat and chest are commonly roused by an attempt to drink and this is so painful that the patient cannot again be induced to try. After this any suggestion of drinking, the offer of drink, the noise of trickling water, the sight of water, the sight of a vessel in which the water was contained, or even of a clear shining surface of glass or metal is likely to bring on a paroxysm. This hydrophobia is peculiar to man being rarely seen in rabid animals. During a paroxysm dyspnœa is extreme, respiration is gasping or sighing, and in the attempt to dislodge the tenacious mucus which is present in the throat, hoarse or shrill inarticulate sounds are emitted which have been supposed to resemble the bark of the dog. There is a sense of closure of the throat and of rising of the stomach, and retching or even vomiting may ensue. Hyperæsthesia, reflex irritability, and exaltation of the special senses, now become extreme, so that a paroxysm may be brought on by the slightest disturbance, a current of air, a bright light, the rustling of a dress, the noise of a footfall, the noise even of talking, or a slight touch. The “tendon reflex” and skin reflex are often much encreased. During a paroxysm there are muscular trembling and clonic spasms,—sometimes opisthotonos. The intervals of complete relaxation, however, serve to distinguish from tetanus. The face is red and drawn, the eyes congested and sometimes squinting, the pupils dilated and the expression one of suffering, apprehension and horror. Mental disorder appears sooner or later, the speech is disconnected, with indication of delusions from which the patient may at first be recalled by the attendant. There is, however, a constant disposition to be reticent, morose and above all, suspicious, as shown by the absence of a direct look, and the frequency of side glances as though in expectation of a hidden danger. This may even rise to mania, the patient charges those about him with having caused his sufferings, or with conspiracy to injure him, and he may seek to defend himself with hands, feet, teeth or any available object. The necessary restraint aggravates and prolongs the attack. On its subsidence the patient collects his scattered senses, regrets, apologizes, and warns against future occurrences of the same kind which he realizes to be beyond his control. Sometimes the delusions continue during the remission as well. Sexual excitement is common in man as in animals.

The convulsive paroxysms may last ½ to 1 hour, and they tend to encrease in duration and force. A violent paroxysm may cause sudden death from asphyxia or apoplexy.

Sooner or later exhaustion and paresis appear. The convulsions become gradually weaker, the reflex irritability and hyperæsthesia abate, and the patient may become once more able to swallow, but an ascending paralysis, beginning in the limbs spreads over the body and death occurs in from one to eighteen hours. In the paralytic stage there may still be slight jerking of the muscles, or tremors, but violent convulsion no longer occurs, and there is extreme prostration, with hurried, rattling breathing, small, weak, irregular pulse and finally, stupor and coma.

Diagnosis in man. The only additional point, to those already stated for animals, is in regard to lyssophobia. This false form of hydrophobia is usually fortified by the fact of a bite, but as a rule it lacks the exaltation of common sensation and of the special senses which characterizes genuine hydrophobia. Very often also there is a flaw in the history, the dog that inflicted the bite is unknown and may still be alive, in which case no medicine is so good as to bring the healthy dog into the presence of the patient. The dog may have been killed by an excited community without any identification of his symptoms as those of rabies or any post mortem examination to throw light on his case. The attack may have come on after a conversation on the subject of the bite, or of rabies, and perhaps, as in the case of the Montpellier cadet, long after and when the patient had for the first time heard that the dog that bit him had been mad. It may be that rabies does not exist in the district and that no other victim in man nor beast can be adduced. It may be that the patient has a nervous organization or is subject to hysteria, and therefore specially predisposed to any disease of the imagination. Such cases cannot be accepted as rabies until a successful inoculation has been made on one or more animals.

RABIES AND HYDROPHOBIA. LESIONS. TREATMENT AND PREVENTION.

Lesions: blood fluid or clot diffluent. Fauces, pharynx and larynx congested, exceptionally ulcerated. In dog, mouth cyanotic, with tenacious mucus, sublingual petechiæ and erosions, stomach contains many foreign bodies, but no food, small intestines and cæcum empty, and like stomach congested: petechiæ on skin and elsewhere, cutaneous and cardiac veins gorged, hyperæmic liver, kidneys and bladder: brain congested, capillaries dilated or blocked, hæmorrhagic, leucocytic collections in lymph spaces, nerve cells swell up with hyaline bodies near nuclei, and neuroglia has hyperplasia, especially near the respiratory centre. Congestion of nerves. Leucocytosis. Therapeutic treatment: Orrotherapy: of little avail. Nerve sedatives; darkness, quiet, nutritive enemata, chloroform, chloral, etc. Prevention: eradicate the virus; muzzle all dogs absolutely, under heavy penalty, for one year; Gower’s view; examples of muzzling; collar with name and owner, shoot all unmuzzled dogs, cage for 6 months bitten dogs and cats, also all imported dogs, shut up in cage for 10 days all dogs that have bitten; treatment of bites, tourniquet, cup, suck through tube, wring wound, cauterize—hot skewer, cautery, mineral solid caustic, mineral acids on pledget or through a tube; Pasteur method: emulsion of spinal cord (of rabid rabbit) after aseptic æration in vitro for 3 to 14 days, injected in graduated doses for 21 days, table of doses, table of mortality; Orrotherapy: by blood serum of immune animal: advantages, disadvantages—technique: Use of sterilized brain matter from rabid animal: experiments; protection by snake venom.

Pathological Anatomy. The blood is fluid or the clot diffluent. Congestion of the fauces, pharynx and larynx is patent during life but may have disappeared after death. Yet I have seen extensive ulceration of the vocal cords in a rabid cow. The congestion may extend to the trachea bronchia and lungs. In dogs the buccal mucosa is often cyanotic, covered with a thick mucus, and may present sublingual ecchymoses and erosions, and wounds of various kinds made by objects bitten or swallowed. The stomach in the same animal is usually almost pathognomonic, being filled with foreign bodies of all kinds—straw, hay, hair, wood, coal, pebbles, pieces of metal, cord, leather, cloth, earth, sand, etc.—the result of the depraved appetite. There is an absence of normal food principles in stomach and small intestines and the cæcum and colon are usually empty. The gastric mucosa is congested, and may be wounded and its contents mixed with blood. Such a condition of the stomach in a dog, that has been bitten, and which after a customary incubation period has shown symptoms like those of rabies, is virtually diagnostic.

The following lesions are common to man and animals: Marked emaciation, cyanosis or petechiæ in skins that are naturally white, early sepsis, cutaneous veins and heart gorged with dark inspissated blood, hyperæmic liver and kidneys, and slightly congested, petechiated empty bladder.