Causes: infection from animals and their products, from soil, by flies, by dust. An industrial disease, of workers among animals and animal products. Wounds as infection atria, ingestion anthrax, inhalation. Lesions: malignant vesicle, anthrax œdema, intestinal anthrax: pulmonary anthrax. Symptoms: malignant vesicle, œdematous anthrax, intestinal, pulmonary. Prevention. Treatment: caustics: antiseptics, excision of nodule and subsidiary glands, mercurial ointment, iodine, sodium bicarbonate. For intestinal anthrax: emetic, oleaginous purgatives, potassium iodide, sodium salicylate, iron muriate, heart stimulants. For pulmonary anthrax: inhale chlorine, iodine, bromine, phenic acid, eucalyptol, oil of cinnamon, sterilized cultures of prodigiosus, pneumococcus of Friedländer, bacillus pyocyaneus, staphylococcus aureus, or streptococcus: blood serum of immune animals: blood serum (sterilized) of anthrax cattle.
Causes. Anthrax in man is usually the result of contamination by infected animals or their products. It is quite possible that man, like animals, may be infected directly from the soil or water, or from the same source through the medium of flies or windblown dust, yet undoubted cases of this kind are rare or unrecognized. The animal origin of the disease, as regards man, makes this largely an industrial affection, attacking shepherds, cattlemen, horsemen, farmers, drovers, butchers, veterinarians, tanners, and workers in hides, wool, hair, bristles, furs, hoofs, bones, rags, felt, glue, and even leather. The sound skin is sufficient protection, but the slightest abrasion may form an infection atrium. Workers in tanneries and those who live near them are notoriously subject to anthrax. The hides must of course be drawn from an anthrax region. Russian, Armenian, South American, Australian and African hides have an especially bad reputation. The British Medical Journal, May 21st, 1898, records cases occurring in postal clerks who had to handle foreign parcels bound with strips of hide. Proust records cases from handling Chinese goat skins (Bull. de l’Acad. de Med. 1894). Infection may also occur through leather made from infected hides as proved experimentally on Guinea pigs.
Hair has long been recognized as a frequent medium of infection and outbreaks among brushmakers have been recently recorded by Gerode, Sarmont and Chauveau. (Compt. Rend. de l’Acad. des Sc. 1893). Trousseau reports twenty cases in Paris, all contracted from South American horse hair. Wool from infected countries is often dangerous and has given rise to special names for the disease (wool-sorter’s, rag-picker’s) which may be developed in the lungs from inhalation of the dust. In the same way those who handle bones about fertilizer, glue and rendering works, are particularly exposed. The agency of insects in man is undoubted. In sixty cases recorded by Dr. Bell, fifty-four were on the face, two on the hands, one on the wrist and one on the forearm. This is mainly due to blood-sucking flies, yet Heim incriminates the coleoptera as well (Compt. Rend. de Soc. de Biol. 1894). Wounds of all kinds contribute to inoculation, hence, the presence of burdocks, thorns, thistles and the like in the matted wool or hair is often a direct cause of infection.
The infection may be transferred on surgical instruments, and in these days of hypodermic medication the greatest care is necessary to prevent infection through the needle.
As in animals man suffers from ingestion and inhalation of the bacillus; and sometimes widespread mortality comes in this way. Meat just killed may be thoroughly disinfected by the secretions of a healthy stomach, yet the bacillus may pass through in an envelope of fat, in an undigested mass or during an attack of dyspepsia, and infect the intestines. The spores are proof against the gastric juice, and as they are produced in a few hours after death the meat of an anthrax animal must always be considered as exceedingly dangerous.
Man is much less susceptible than some other animals and the disease wherever inoculated tends to remain for a time localized, in the skin, the lungs or the bowels. The forms of the disease are malignant carbuncle (pustule), malignant œdema, intestinal anthrax, and pulmonary anthrax.
Lesions. The morbid histology is in the main the same as described in animals. In the protracted cases there is the same dark nonærated blood, forming a loose coagulum, the crenated or distorted blood globules aggregated in irregular masses, the escape and solution of the hæmoglobin so as to stain the white tissues, the enlargement of the spleen which is gorged with dark blood, and the hyperæmia of the liver and lymph glands. There is in the affected tissues and usually in the blood the characteristic large bacillus anthracis.
In the malignant vesicle there is first a minute, firm central, dark nodule like an insect bite with a lighter colored areola, and showing not only hyperæmia, but blocking of the capillaries, and minute areas of extravasation. Somewhat later the dark centre is surmounted by a small vesicle, beneath which the tissues are becoming necrotic, and the area of congestion and extravasation has extended and thus the local disease advances by a constant invasion of new tissue which in its turn becomes the seat of coagulation necrosis. On microscopic section the central necrotic part shows the cells of the rete Malpighi separated by a finely granular coagulum, and the papillæ are greatly swollen by serous and hæmorrhagic exudate. The cell nuclei are necrotic and no longer take a stain. The capillaries are gorged with red globules and bacilli. In the surrounding tissues there is much congestion and exudation, with numerous points of extravasation, but the abundant multinuclear cells retain their staining power.
In Anthrax Œdema, which appears in parts like the eyelids, neck and forearm where there is an abundance of loose connective tissue and a scanty blood supply, there is no firm central nodule, but a diffuse soft infiltration, with points or patches of a yellow or reddish color. The capillaries are congested, with minute emboli and extravasations and there is an excessive and rapidly spreading exudation. It shows a great tendency to early general infection and may end in vesication and local gangrene or in favorable cases in resolution.
In Intestinal anthrax (intestinal mycosis) the lesions are usually concentrated on the small intestines, while the stomach and large intestines in the main escape. The walls of the bowel are of a dark red, and greatly thickened by exudation and extravasation which also mixes with the ingesta giving it a dark bloody tinge. At intervals on the mucosa are nodular hæmorrhagic swellings, from the size of a linseed to a pea, with commencing necrotic changes or the formation of sores. The mesenteric glands are swollen, infiltrated and hæmorrhagic, and like the other lesions abound in bacilli. Hyperæmia and engorgement of the liver and above all of the spleen are the rule.
In pulmonary anthrax (wool-sorter’s disease) a sanguineous liquid is found in the lower trachea and bronchia, and not infrequently in the pleuræ and pericardium. The bronchial glands are swollen, hyperæmic and often hæmorrhagic, and exudations and extravasations may be found in the mediastinum and lungs. Lesions of the intestines and spleen are common, and in all alike the bacilli are found.
In certain cases the anthrax lesions may be found in the brain, or any part of the body but in all they show the same general characters and the same specific microbe.
Malignant Vesicle (pustule). Symptoms may vary somewhat but are in the main as follows: An itching papule appears in the seat of inoculation, which might be mistaken for an insect bite but for the dark red color of the centre. Occurring on an uncovered portion of the skin, in an anthrax district, or near a factory where anthrax products are likely to be used, this should at once create suspicion. Soon the dark centre is covered by a small vesicle with clear contents which later become bloody. Within 24 or 48 hours the vesicle dries up, becoming firm, resistant and brownish red or blackish gray, and apparently gangrenous. The swelling has meanwhile extended to ½ or ¾ inch in diameter and a row of fresh vesicles may appear which in their turn give place to a necrotic slough. In this way extension may take place, the sore retaining a more or less rounded form, and necrosis extending from the centre in every direction. The necrotic mass, however, remains firmly adherent to the adjacent tissues until separated by the work of suppuration which ensues in favorable cases. The disease is attended with more or less fever, chill, hyperthermia, nausea, diarrhœa, with aching of head, back, and limbs and unfavorable cases may merge into acute and fatal general anthrax. The mortality is about 20 per cent., though in special epidemics it has reached 80 per cent. (With the pustule on the face 25 per cent.; on the lower limb 5 per cent., Norris). The prognosis is favorable with a free concentration of leucocytes, a moist condition of the wound and above all a liberal invasion of pus cocci. It is unfavorable when the wound is dry, when the drying slough remains firmly adherent and when the adjacent lymph glands become implicated. In non-fatal cases it may be difficult to find the bacillus.
Anthrax Œdema. This is less easily diagnosed than malignant vesicle, and appears where the connective tissue is loose, abundant and little vascular, from direct local inoculation, or as a concomitant of internal anthrax. It is a flat, rapidly extending swelling, with the skin comparatively unaltered, though at points yellowish or reddish discoloration indicates congestion and extravasation. Not being limited by firm tissues nor aggregations of accumulating leucocytes it tends to a speedy general infection with all the febrile manifestations of that condition. Thus chills, nausea, hyperthermia, dusky reddish or brownish mucosæ, cephalalgia, rachialgia and profound prostration assist in diagnosis. The bacilli in the blood and exudate would serve to confirm the conclusion.
Intestinal Anthrax. Here again the ingestion of anthrax products, and the simultaneous attack of a number of people who have taken such materials will often assist in diagnosis. There may have been for some days indications of local bowel lesions, such as chilliness, elevation of temperature, nausea, headache, and giddiness. Suddenly these become more violent, there is vomiting and sanguineous diarrhœa, extreme anxiety and debility, cyanosis, dyspnœa, and it may be the appearance of petechiæ on the skin and mucosæ or even of local swellings. In some cases there are convulsions or other symptoms of nervous disorder and in others extreme prostration and collapse. The bacillus is not always to be found in the circulating blood, but may be detected in sanguineous excretions, or by cultures.
Pulmonary Anthrax. (Woolsorter’s disease). Here again the occupation of the patient assists in diagnosis. For two to five days prodromata similar to those of intestinal anthrax may be noted. The difficulty in breathing, dyspnœa, cough, cyanosis and sense of constriction of the chest are especially diagnostic. Suddenly all these symptoms are aggravated, respirations become 30 to 40 per minute, the pulse 120 to 150, the temperature 104° to 106°, and there is a frothy bloody expectoration in which the bacilli may be detached. There may be indications of intestinal, cerebral or nephritic lesions, and bloody discharges. Death usually occurs in 12 to 48 hours from collapse, or coma, from asphyxia or in convulsions. The few recoveries are tardy and tremors and spasms persist for a length of time. In the most favorable cases the disease does not proceed beyond the initial stage.
Prevention is the most important consideration and this will include all that has been stated above with regard to the restriction of the disease in flocks and herds, the drainage and improvement of anthrax lands, the seclusion, destruction, deep burial or cremation of carcasses without autopsy or incision, the disinfection of stalls, secretions and all contaminated products, and the suppression of all traffic in anthrax products—meat, milk, blood, guts, bones, horns, hoofs, hair, wool, bristles, etc., or the thorough disinfection of the same. Above all, is the adoption of personal precautions. No one should handle anthrax animals, nor suspected products who has any sore or abrasion on hands or face, or such sore may be temporarily covered with a film of albuminate of silver, or the hands may be washed with a solution of mercuric chloride (1:500), or chloride of lime (1:200). If persons must work in wool or textile products which are open to suspicion a respirator is an obvious precaution, and this may be disinfected by live steam at intervals.
Treatment of malignant pustule is mainly surgical. At the outset the thorough destruction of the dark central point or nodule with a red hot needle or powerful caustic will be sufficient. Even when the pustule is fully formed, its free excision with as much of the surrounding infiltrated tissue as can be safely accomplished and the free application of caustics will usually succeed. Potassa fusa, or zinc chloride (1:3), or mercuric chloride or iodide in powder with or without calomel, or pyoktanin, or formaline, or iodized phenol may be named as especially applicable. Injections of carbolic acid (5 or 10:100) into the indurated centre and infiltrated periphery have proved very successful. In the case of Kaloff, when the excision of the nodule followed by the local use of carbolic acid solution, failed to prevent implication of the inguinal and pectoral glands, violent fever, prostration, and diarrhœa; the excision of the affected glands and the free use of phenic acid solution (5:100) in the adjacent tissues led to speedy improvement. Some surgeons make a crucial incision of the pustule and apply caustics freely. Muskett has been successful in excising the nodule, filling the wound with ipecacuan powder and giving the same agent internally. Many mild cases, or those that occur in refractory systems will however recover spontaneously or under a less drastic treatment. In the anthrax districts of Russia mercurial ointment is rubbed on the sore, and the application of tincture of iodine or iodized phenol to the raw sore or incised nodule and surrounding infiltration is often successful.
Camescasse has claimed great success by incising the swelling, applying tincture of iodine freely, and then wrapping in cloths kept wet with a solution of 5 drachms of bicarbonate of soda in a quart of tepid water.
When systemic reaction has set in it is desirable to have resort to general medication as for internal anthrax.
Treatment of Anthrax Œdema must follow the same rule. Free incisions into the œdematous tissues with the application of antiseptics, solution of mercuric chloride or biniodide (1:1000), or the injection of the whole infiltrated area and around it with the same agents, with phenic acid (5 or 10:100), or with pyoktanin (1:1000) will prove useful, and as in the malignant pustule the surface should be kept disinfected by a compress wet in solution of the mercuric chloride or biniodide, carbolic acid, iodized phenol, formalin or pyoktanin. If the pain of these applications is very acute cocaine will be demanded or even ether. If ether is applied to the surface its evaporation will cool the parts and retard the proliferation of the bacillus. Under other conditions cold water, pounded ice or snow may be applied.
Treatment of Intestinal Anthrax. When anthrax flesh has been eaten, or when there are symptoms of incipient intestinal anthrax, the first resort is an emetic of ipecacuan, followed by an active oleaginous purgative to clear the prima viæ of bacilli and their toxins. To these may be added potassium iodide, pyoktanin, sodium salicylate, quinine or tincture of muriate of iron, by way of keeping in check the multiplication of bacilli. To counteract depression and heart failure digitalis, strophanthus or strychnia with alcoholic stimulants may be resorted to.
In Pulmonary Anthrax the same principles are applicable. The patient may be made to cautiously inhale gaseous chlorine, iodine or bromine or a solution of iodide of potassium in an atomized condition. The vapor of carbolic acid, eucalyptol, or oil of cinnamon may be tried.
The irritable stomach may be soothed by oxide of bismuth, with milk, beef tea and other bland nutritive or stimulating draughts.
The grave character of internal anthrax, however, is such that resort may be had to one of the various antitoxins, antidotal cultures, serums, and immunizing agents that have proved useful in different hands. Unfortunately such agents do not seem to act in the same manner on all genera, and what has been effective in one of the lower animals may fail in the human being. Thus Roger found that sterilized cultures of bacillus prodigiosus retarded or obviated anthrax in rabbits, but hastened its progress in the Guinea pig.
The sterilized cultures of the pneumococcus of Friedländer (Buchner) of the bacillus pyocyaneus, or of the staphylococcus pyogems aureus, (Pawlowsky) when injected subcutem have proved antidotal to anthrax. Emmerich has successfully used erysipelas serum subcutem in the treatment of anthrax. (Münch. Med. Woch. 1894). The sterilized cultures of the streptococcus erysipelatos therefore offer themselves as promising curative agents. The same is true of the sterilized cultures of the bacillus pyocyaneus (Woodhead and Cartwright-Wood).
The blood serum of animals that are naturally immune (frog, white rat, pigeon, dog,) is bactericidal and to a certain extent antidotal to the bacillus anthracis, but that of an animal which is naturally susceptible but which has been artificially immunized has proved much more potent. In the experience of the writer this potency attaches no less to the blood of an animal in the advanced stages of the disease. In adult cattle he has found the symptoms of anthrax subside under two successive daily doses (4cc.) subcutem of the sterilized blood serum of one of the herd which had just died. Relapses were observed several days after the serum treatment was abandoned. In experiments on rabbits two check animals with anthrax inoculations died at the end of 3½ and 4 days. Of six inoculated with anthrax and injected from one to three times with sterilized (anthrax) blood serum one recovered, and the others died, one at the end of the 7th, two of the 6th and two of the 5th day. In this connection it may be stated that successful treatment by leucocytes is claimed, (Pawlowsky) and that one of the effects of serum treatment is the destruction in part of the globules and the release of nuclei, and in this we may have an explanation in part at least of the therapeutic action of the serum from the infecting and immunized animal.
Protective serums may be utilized by hypodermic injections daily or every second day for a week, giving time for the disposal of the bacilli present in the system. In the intestinal anthrax they may be given by the mouth and injected into the peritoneal cavity. In pulmonary anthrax they may be introduced into the trachea, bronchi and pleural cavity.