resistant to disinfecting agents. Animals acquire the disease through abra-
sions such as insect bites, etc., by feeding upon the flesh of other animals dead
from the infection and by grazing over fields where the bacilli are present,
for these have been found upon the herbage over the buried bodies of animals
which have died of anthrax.

Symptoms. The incubation of anthrax is usually about one week and
for convenience in description the disease may be considered as occurring in
two forms, the external and the internal.

External Anthrax, a. Malignant pustule occurs as a result of inocu-
lation and most often begins upon the exposed surfaces of the face, hands
or arms. The first symptom is pain, itching or burning in character, at the
site of inoculation. Soon a reddened spot appears which quickly becomes
papular and then vesicular, the vesicle containing clear or bloody serum.
The surrounding tissues become indurated and, the original vesicle bursting,
other vesicles develop about the indurated area. The induration extends
and becomes darkened at its center, a brown eschar usually appearing within
36 hoiu-s. The neighboring tissues are oedematous and, the infection spreading
along the lymphatic channels, these become reddened, swollen and tender
and the adjacent lymph ganglia are enlarged.

There is accompanying constitutional disturbance, the temperature and
pulse rate being elevated and other symptoms of an acute infection being
present. Later the temperature may fall below normal and in fatal cases
death supervenes after from three to five days. In favorable cases with mild
constitutional symptoms the vesicles may scab and with the induration gradu-
ally disappear or the eschar may slough away leaving the wound to heal.

h. Malignant anthrax cedema usually begins in the eyelid, spreading thence to
the face; it also may occur in the hands or arms; papules and vesicles do not
appear but there is marked oedema which may go on to gangrene. The
constitutional symptoms may precede the local manifestations and are usually
of severe type. Recovery from this form of the disease is practically unknown.

A marked characteristic of both forms of the infection is the absence of
mental anxiety, the mind often remaining wholly unaffected.

Internal anthrax also occurs in two forms, a. Intestinal anthrax or
mycosis intestinalis results from the ingestion of the meat or milk of infected
animals or from the transference of the contagium of external anthrax to the
digestive tract. There is likely to be a chill at the onset which is succeeded
by the symptoms of intense intoxication such as vomiting, diarrhoea with
bloody stools, general pains, fever and abdominal tenderness. In the severe



124 • THE INFECTIOUS DISEASES.

cases the respiration is difficiilt, cyanosis and pronounced mental symptoms
are present and there may be extravasations of blood from the mucous
membranes or petechial haemorrhages into the skin. There is splenic en-
largement, the blood is dark, remains uncoagulated for a considerable period
post mortem and in the later stages of the disease may contain the bacillus
anthracis. Convulsions may be observed shortly before death.

b. Wool sorter's disease is seen amongst those who work in wool or hides,
especially those imported from South America or Russia, and is the result
of the inhalation or of swallowing the contagium. There is seldom an
external lesion and the onset of the infection is usually abrupt with a chill,
high temperature, general pains and prostration. The heart action is rapid
and feeble and there is dyspnoea and thoracic pain. Cough with accompanying
physical signs of bronchitis is not infrequent. Death may occur in collapse
within 24 hours or the disease may be prolonged with vomiting, diarrhoea
and marked cerebral syniptoms. In such cases the capillaries of the brain
have been found to contain the bacillus anthracis in enormous numbers.

Rag picker's disease is the name given to a pulmonary and pleural anthrax
infection which is accompanied by a general intoxication.

The diagnosis of anthrax of the external form may be made from the local
appearances and from the history. Bacteriological examination of the con-
tents of the vesicle may reveal the presence of the specific micro-organiam.
Inoculation experiments are also useful. Internal anthrax is less simple
of diagnosis but may be suggested by a history of exposure.

The prognosis is distinctly bad, particularly in the internal types.

Treatment. Much may be done in the way of prevention by the disin-
fection of hides, wool, rags, etc., by means of steam under pressure. Hides,
unfortunately, are damaged by this process. All animals dead from the
disease should be burned, not buried, grazing over infected pastvires should
be prohibited and the thorough disinfection of infected buildings is of much
importance.

The site of the lesion in external anthrax should be excised if possible or if
not deep crucial incisions are to be made and followed by cauterization with
the thermo-cautery, phenol or a solution of potassium hydrate. The wound
should then be dressed with a strong solution of phenol or powdered with
pure mercury bichloride. General or local anaesthesia may be necessary.
Injections beneath the skin of the siurrounding parts may be effectual in
preventing the spread of the infection. Such solutions as ^ percent, phenol;
two to five percent, tincture of iodine; iodine one part, potassium iodide
two parts, water one thousand parts, may be injected several times daily.
Mercury bichloride is also useful in this connection. The technique of such
injections is as follows: At a distance of about ^ an inch from the margin
of the indurated area the needle is inserted and the injection made; other



GLANDERS. 12$

injections are given outside the periphery of the inflammation at such intervals
that the tissue infikrated v^^ith the chosen solution shall act as a continuous
barrier to the progress of the infection. The injection of the solution of
iodine and potassium into the enlarged lymph glands is also advised.

Internally we may give lo to 30 drops (0.66 to 2.0) of tincture of iodine
daily or ^ an ounce (15.0) every two hours of the mixture of iodine and potas-
sium iodide mentioned above. Stimulants such as alcohol and strychnine
should be prescribed as indications arise and the dietary should be as plentiful,
nutritious and as digestible as possible.

Internal anthrax is likely to be little influenced by treatment. The bowels
should be freely moved at the onset and kept open during the course of the
disease in order that, if possible, the toxic matters may be removed; the treat-
ment described above may be employed and the free exhibition of intestinal
antiseptics is advocated.

An antiserum for the treatment of anthrax has been elaborated and from
the results claimed would seem to merit a trial.

GLANDERS.

Synonyms. Farcy; Malleus Humidus.

Definition. An infectious disease particularly of the horse but com-
municable to other animals such as the sheep, rabbit, cat, dog and mouse;
cows enjoy immunity. The disease is manifested by nodular growths in the
nostrils (glanders) and under the skin (farcy).

.Etiology. The disease is rare in man but may be seen in stablemen
and others who work about horses. Its specific cause is a micro-organism,
the bacillus mallei. The infection is transferred to man by inoculation
through an abrasion of the skin or through a mucous membrane, the conta-
gium being given off in the discharges from the diseased animal.

Pathology. The characteristic lesion of glanders is the appearance of
granulomatous tumors of varying size, composed of epithelial and lymphoid
cells and containing the bacillus mallei. These tumors occur beneath the
skin and on the mucous membranes where they soon break down forming
respectively abscesses and ulcerations. The nodules have also been observed
in the viscera and in the nervous and osseous systems.

Symptoms. Acute and chronic forms of both glanders and farcy occur
in man.

The incubation period of acute glanders is from three to five days. The
onset is characterized by the usual symptoms of beginning febrile disease;
at the site of the infection there are redness and swelling, the nasal mucous
membrane in the vicinity becomes first dry and congested, the appearance
of the nodular tumors rapidly follows, and these soon break down becoming



126 THE INFECTIOUS DISEASES.

ulcers which discharge a muco-puriilent or bloody secretion. The infection
may cause severe frontal headache due to accompanying involvement of the
sinuses in this neighborhood. The submaxillary and cervical lymph glands
become enlarged and may suppiu-ate and the inflammatory process spreads
to the nasal septum, to the mouth, pharynx and even to the lower air passages,
causing pain on swallowing, cough with foul expectoration, and even pneu-
monia. A papular eruption which soon becomes pustulous and may be
mistaken for smallpox may appear upon the face and upon the skin over the
articulations.

Chronic glanders is difficult of diagnosis. Its symptoms resemble those
of a chronic rhinitis or laryngitis for either of which it is likely to be mistaken.
There are ulcerations of the nasal mucous membrane. The diagnosis may
be made by inoculating the peritonaeum of a guinea pig with the nasal secre-
tion or with a culture grown from this substance. If glanders is present
the testicles of the animal become swollen and inflamed within a few days
and ultimately suppurate. The guinea pig dies within three or four weeks
and nodules are found in the abdominal organs.

Acute farcy is evidenced by the symptoms of an acute infection accom-
panied by a subcutaneous nodule or an ulcer with a foul secretion. The
neighboring parts become congested and oedematous and adjacent lymphat-
ics are involved; "farcy buds," which are subcutaneous nodules along the
course of the lymph vessels, develop and may suppurate. Intramuscular
abscesses and articular swellings may appear and rarely a pustular rash
occurs. The nose is not affected and the urine may contain the bacillus
mallei.

Chronic farcy is characterized by localized subcutaneous nodules, usually
occurring upon the extremities; their development is sluggish and while
they break down, forming abscesses or ulcers, there is no marked lymphatic
involvement. The course is protracted and pyaemic symptoms or acute
glanders may develop.

The diagnosis in acute glanders is seldom difficult tut in the chronic form
is less simple. Recently the agglutination test has been employed since it
has been proven that while normal horse serum agglutinates glanders bacilli
in a dilution of i to 200, that of a horse affected with glanders will agglutinate
a I to 1000 dilution. MaUein, a product of the growth of the glanders baciUus
analogous to the tuberculin of tuberculosis, may be employed in diagnosis.
Inoculation with this substance causes a rise of temperature when glanders
is present, a rise in horses of 3.5° F. (2° C.) being considered proof that the
animal is diseased, while an elevation of 1.25° F. (0.75° C.) is considered sus-
picious. Direct animal inoculation will quickly determine the presence
or absence of the infection and implantation of cultures from the secretion
upon cooked potatoes shows within three or four days an amber colored



ACTINOMYCOSIS. 1 2 7

film, becoming by the end of a week red and encircled by a pale green area.

The prognosis in the acute forms is almost invariably fatal. In the chronic
types about half the cases recover.

Treatment consists in the early excision and cauterization of the lesion;
antiseptic dressings should then be applied. In the nasal form of the infec-
tion antiseptic sprays and gargles of dilute phenol or hydrogen dioxide are
to be employed. Farcy buds should be incised and dressed antiseptically.
Mallein has been employed in animals and has been administered internally
to human beings with no very positive results. The patient's nutrition should
be kept up by a supporting diet, symptoms should be combated as they arise
and stimulation prescribed when indicated.

ACTINOMYCOSIS.

Synonyms. Lumpy Jaw; Big Jaw; Bone Tumor; Swelled Head.

Definition. A chronic infectious inflammatory disease of cattle and pigs,
transmissible to man and caused by the strepfothrix aciinomyces or ray fungus.

.Etiology. The disease is common in cattle, is more frequently seen in
man in Germany than in England or America and affects males more fre-
quently than females. The fungus probably reaches the human organism
upon the ingested food. Direct infection with meat or milk has, however,
never been proven. It has been shown that the disease may be conveyed
to cattle upon oats and other grains and it is not improbable that man may
contract the disease in the same manner. The infection takes place usually
through the mouth, teeth or throat, rarely through the skin or respiratory
passages.

Pathology. The characteristic lesion is a miliary nodule, made up of
a central mass of fungi radiating in all directions and surrounded by granula-
tion tissue. The size of a single nodule is about that of a millet seed but
numbers of these may be aggregated into tumors the size of a base-ball;
about the larger tumors the connective tissue is greatly proliferated and finally
suppuration with abscess formation takes place.

Symptoms, a. The digestive tract. The infection usually takes place
through the mouth or decayed teeth, the jaw becomes swollen and the face so
enlarged that the condition may be mistaken for sarcoma; sinuses discharging
pus are often present. Rarely the tongue, pharynx, intestines or liver may be
involved primarily or secondarily as a result of metastasis. Actinomycotic
appendicitis has been observed and the fungi have been demonstrated in the
stools.

h. Pulmonary actinomycosis. Infection of the lungs by the ray fungus
is not infrequent and occurs in three types. First, a form with lesions resem-
bling those of chronic bronchitis, the sputum containing the fungi. Second, a
miliary form in which tubercles occur resembhng those due to thebaciUus



128 THE INFECTIOUS DISEASES.

of Koch but in which the actinomyces are demonstrable. Third, a destructive
form characterized by interstitial lesions and abscesses which may form
cavities. The pulmonary type of the disease may occur synchronously
with involvement of the jaw or other parts. The cough is accompanied by
a foetid, sputum, in which the actinomyces may be demonstrated, and fever,
which is usually septic in character if suppuration has taken place. The
course of the infection is protracted, the average duration being about lo
months; recovery is rare.

c. Actinomycosis of the skin is a chronic condition characterized by the
development of cutaneous swellings which break down and result in ulcers
in the discharge of which the fungi have been found.

d. Cerebral actinomycosis is a very rare type of the disease. It is charac-
terized by the formation of abscesses in the brain, the pus of which may con-
tain the myceliimi.

The diagnosis can be assured only upon demonstrating the fungi in the pus
or other discharges from the lesions; unless this can be done the condition
is likely to be confounded with pyemia, which, in actuality, it is.

Actinomycosis of the jaw may be differentiated from sarcoma by its more
protracted course, greater tendency to suppuration and the presence of actin-
omyces.

Treatment in general consists in the administration of potassium iodide
in doses of from 30 to 75 grains (2.0 to 5.0) daily, gradually increased to 90
to 120 grains (6.0 to 8.0) and the maintenance of the patient's strength by
nourishing food, arsenic and other tonics. In pulmonary actinomycosis
in addition to the internal administration of potassium iodide, antiseptic
inhalations should be employed as in foetid bronchitis (see p. 623) and the
vapor of iodine is particularly effectual. The internal measures applicable
in the foetid form of bronchitis are also useful and especially the preparations
of eucalyptus. Actinomycosis of the intestine necessitates attempts at
achieving intestinal antisepsis.

If the tumor is so situated as to allow of excision this should be performed
and the dead bone and infected tissues removed, the wound and sinuses drained
and irrigated with a solution of iodine and potassium iodide or of iodoform
and glycerin. Cauterization of the infected tissues with zinc chloride is
also recommended. Intestinal actinomycosis with localized pus foci neces-
sitates laparotomy and in the cerebral type if the symptoms suggest a localized
abscess surgical interference is also indicated.

EPIDEMIC STOMATITIS.

Synonyms. Foot and Mouth Disease; Aphthous Fever; Aphthae Epizo-
oticae.

Definition. An acute infectious disease of animals most frequently seen



MILK SICKNESS. 1 29

in cattle, sheep, and pigs, occurring rarely in dogs, cats and fowls, and char-
acterized by the presence of vesicles and ulcers upon the buccal mucous
membrane, in the clefts about the feet and upon the udders. It may occur
in epidemics, when it spreads with great rapidity and may entail consider-
able loss to the grazing interests. The infection is transmissible to man.

JEtiology. The disease occurs in human beings as a result of drinking
the milk or more rarely of eating cheese or butter from infected cattle, and
through contact with the contents of the vesicles in the mouths or upon the
teats of the diseased animal. Meat from such animals does not appear to be
infective. No micro-organism has yet been demonstrated to be responsible
for this disease and while it may be of microbic origin the specific cause is
probably too small to be visible through the microscope since the contents
of the vesicles retains its infective properties after passage through a porcelain
filter which is impermeable to the most minute bacteria. Animals may be
rendered immune by a vaccine elaborated by Loffler.

Infants may be infected by milk from diseased cows and a connection has
been suggested between the aphthous stomatitis of children and foot and
mouth disease.

Symptoms. After an incubation period of from three to five days the onset
is marked by a rise in temperature, malaise, anorexia and digestive distur-
bance which may be preceded by a chill or chiUy sensations. Vesicles con-
taining a yellow serum appear upon Hps, tongue and pharynx; the mouth
is hot, its lining is red and swollen and there may be interference with speech
and deglutition; the saliva is increased. An eruption of vesicles which may
become pustules appears upon the skin particularly of the fingers and toes,
about the nipples in women and at times over other parts of the body. This
rash may be mistaken for that of smallpox or for vaccinia if it occurs after
vaccination. The vesicles within the mouth may go on to ulceration.

The prognosis is good except in young infants.

Treatment. Prevention consists in boiling all suspected milk and insis-
tence upon cleanUness in the care of animals.

The diseased mucous membrane should be kept clean by means of simple
antiseptic mouth washes of potassium chlorate, boric acid or liquor antisepticus.
The ulcers should be powdered with biunt alum or if this is inefficient, touched
with stick silver nitrate. The cutaneous eruption necessitates the employ-
ment of mild lotions of i to 5 or 10,000 mercury bichloride solution and of
dressings of sterile gauze. In other regards the treatment is wholly symp-
tomatic.

MILK SICKNESS.

Synonyms. The Trembles; The Slows.

Definition. An acute infectious disease of man and the lower animals
9



130 THE INFECTIOUS DISEASES.

formerly common in the Western states but at present seldom seen except
in certain parts of North Carolina. In animals it is termed the trembles.

.Etiology. The disease is most frequently observed in newly settled
lands and seems to disappear as the ground is cultivated and the forests are
cleared Its specific cause is not known but the infection is probably trans-
mitted to man through the milk, cheese and butter as well as by the means of
the flesh of diseased animals. The contagium may have its origin in the
soil and a spiriJl.um has been found in the blood of sufferers, but this as yet
has not been proven to be a distinct aetiologic factor.

Pathology. No characteristic morbid changes have been described,
few autopsies upon human beings having been performed.

Symptoms. After an indefinite incubation period and prodromal symp-
toms lasting a few days and consisting of increasing malaise, headache and
loss of appetite, the onset of the disease occurs This is sudden and marked
by nausea and vomiting, gastric pain, obstinate constipation, pronounced
thirst and moderate rise of temperatiu-e. The mouth is dry, the tongue
tremulous and swollen and the breath is foul and of a characteristic odor.
The pulse is at first full and rapid, later the typhoid state may supervene,
when it becomes small and weak, and pronounced cerebral symptoms, such
as restlessness and irritability which may be followed by a hebetude deep-
ening into stupor or coma, appear. Convulsions may be noted. The severer
and more acute cases may terminate fatally within a few days, in other
instances the disease may be protracted for three or four weeks.

The diagnosis is usually made by exclusion and upon the fact that "the
trembles" is prevalent among the cattle of the neighborhood.

The prognosis is usually favorable although convalescence may be pro-
longed for several weeks.

Treatment. Prevention consists in the avoidance of aU possibly infected
milk, meat or other foodstuffs. The treatment is wholly symptomatic and
eliminative, it being necessary to provide for the removal of the poisons of
the disease from the blood by seciu-ing free action of the bowels, kidneys
and skin, to prescribe stimulation in the form of alcohol, strychnine, ammonia,
etc., and sedatives as indications arise. The dietary should be supportive
and arranged in accordance with that of other acute infections.

GONORRHCEAL INFECTIONS.

The consideration of infection of the male urethra and of the vagina with
the gonococcus is without the scope of this work but this fact does not render
less the importance of the disease. Gonorrhoea is without doubt one of the
greatest scourges with which the human race has to contend and its effects
reach far beyond the seat of the primar}' inflammation. The extent of the



GONORRHCEAL INFECTIONS. I3I

ravages of the infection are prominently brought to notice by the recent
statement of an eminent gynaecologist that probably not less than 80 percent,
of the married women of New York City are suffering from pelvic disorders
of various characters, the result of infection from their husbands whose youth-
ful or later indiscretions become thus responsible for ills that render a woman's
life miserable and end in sterility or even more serious conditions. The
time is past when a specific urethritis is to be looked upon as little more grave
than a cold in the head and considered a part of the education of every young
man. It has been demonstrated that the gonococcus remains active in the
urethral discharge long after this ceases to be purulent in character and even
after years, when the host of this insidious organism believes himself wholly
cured, is capable of as much mischief as when the infection was in its early
stages.

GONORRHCEAL SEPTICEMIA AND PYiEMIA.

These conditions do not differ, so far as symptoms are concerned, from
analogous states resulting from other microbic infections, except that they are
associated with genito-urinary inflammations. The gonococcus may be dem-
onstrable in the blood and the course of the affection varies in severity. The
irregular temperature may continue for a number of weeks and, unless the
endocardium becomes involved, recovery may take place; on the other hand
rapidly fatal cases occm* usually associated with localized pus collections in
different parts of the genito-urinary system.

The most important and frequent local manifestations of general gonor-
rhoeal infection are gonococcal endocarditis and arthritis.

a. Gonorrhoeal endocarditis is a serious condition and for its more
complete discussion the reader is referred to the section upon malignant
endocarditis (p. 556). Gonococci may be demonstrated in the blood and in
the ulcerations or verrucous growths upon the valves. Other cardiac lesions
such as pericarditis and myocarditis may be associated with the endocardial
inflammation.

b. Gonorrhoeal arthritis is a septic inflammation of a joint due to the