Manual of Surgery, Alexis Thomson [new books to read txt] 📗

Fig. 29.—Malignant Pustule, fourteen days after infection, showing black eschar in process of separation. The œdema has largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).

Fig. 29.—Malignant Pustule, fourteen days after infection, showing black eschar in process of separation. The œdema has largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).

Prophylaxis.—Any wound suspected of being infected with anthrax should at once be cauterised with caustic potash, the actual cautery, or pure carbolic acid.

Treatment.—The best results hitherto obtained have followed the use of the anti-anthrax serum introduced by Sclavo. The initial dose is 40 c.c., and if the serum is given early in the disease, the beneficial effects are manifest in a few hours. Favourable results have also followed the use of pyocyanase, a vaccine prepared from the bacillus pyocyaneus.

By some it is recommended that the local lesion should be freely excised; others advocate cauterisation of the affected part with solid caustic potash till all the indurated area is softened. Gräf has had excellent results by the latter method in a large series of cases, the œdema subsiding in about twenty-four hours and the constitutional symptoms rapidly improving. Wolff and Wiewiorowski, on the other hand, have had equally good results by simply protecting the local lesion with a mild antiseptic dressing, and relying upon general treatment.

The general treatment consists in feeding and stimulating the patient as freely as possible. Quinine, in 5 to 10 grain doses every four hours, and powdered ipecacuanha, in 40 to 60 grain doses every four hours, have also been employed with apparent benefit.

Glanders

Glanders is due to the action of a specific bacterium, the bacillus mallei, which resembles the tubercle bacillus, save that it is somewhat shorter and broader, and does not stain by Gram's method. It requires higher temperatures for its cultivation than the tubercle bacillus, and its growth on potato is of a characteristic chocolate-brown colour, with a greenish-yellow ring at the margin of the growth. The bacillus mallei retains its vitality for long periods under ordinary conditions, but is readily killed by heat and chemical agents. It does not form spores.

Clinical Features.—Both in the lower animals and in man the bacillus gives rise to two distinct types of disease—acute glanders, and chronic glanders or farcy.

Acute Glanders is most commonly met with in the horse and in other equine animals, horned cattle being immune. It affects the septum of the nose and adjacent parts, firm, translucent, greyish nodules containing lymphoid and epithelioid cells appearing in the mucous membrane. These nodules subsequently break down in the centre, forming irregular ulcers, which are attended with profuse discharge, and marked inflammatory swelling. The cervical lymph glands, as well as the lungs, spleen, and liver, may be the seat of secondary nodules.

In man, acute glanders is commoner than the chronic variety. Infection always takes place through an abraded surface, and usually on one of the uncovered parts of the body—most commonly the skin of the hands, arms, or face; or on the mucous membrane of the mouth, nose, or eye. The disease has been acquired by accidental inoculation in the course of experimental investigations in the laboratory, and proved fatal. The incubation period is from three to five days.

The local manifestations are pain and swelling in the region of the infected wound, with inflammatory redness around it and along the lines of the superficial lymphatics. In the course of a week, small, firm nodules appear, and are rapidly transformed into pustules. These may occur on the face and in the vicinity of joints, and may be mistaken for the eruption of small-pox.

After breaking down, these pustules give rise to irregular ulcers, which by their confluence lead to extensive destruction of skin. Sometimes the nasal mucous membrane becomes affected, and produces a discharge—at first watery, but later sanious and purulent. Necrosis of the bones of the nose may take place, in which case the discharge becomes peculiarly offensive. In nearly every case metastatic abscesses form in different parts of the body, such as the lungs, joints, or muscles.

During the development of the disease the patient feels ill, complains of headache and pains in the limbs, the temperature rises to 104° or even to 106° F., and assumes a pyæmic type. The pulse becomes rapid and weak. The tongue is dry and brown. There is profuse sweating, albuminuria, and often insomnia with delirium. Death may take place within a week, but more frequently occurs during the second or third week.

Differential Diagnosis.—There is nothing characteristic in the site of the primary lesion in man, and the condition may, during the early stages, be mistaken for a boil or carbuncle, or for any acute inflammatory condition. Later, the disease may simulate acute articular rheumatism, or may manifest all the symptoms of acute septicæmia or pyæmia. The diagnosis is established by the recognition of the bacillus. Veterinary surgeons attach great importance to the mallein test as a means of diagnosis in animals, but in the human subject its use is attended with considerable risk and is not to be recommended.

Treatment.—Excision of the primary nodule, followed by the application of the thermo-cautery and sponging with pure carbolic acid, should be carried out, provided the condition is sufficiently limited to render complete removal practicable.

When secondary abscesses form in accessible situations, they must be incised, disinfected, and drained. The general treatment is carried out on the same lines as in other acute infective diseases.

Chronic Glanders.—In the horse the chronic form of glanders is known as farcy, and follows infection through an abrasion of the skin, involving chiefly the superficial lymph vessels and glands. The lymphatics become indurated and nodular, constituting what veterinarians call farcy pipes and farcy buds.

In man also the clinical features of the chronic variety of the disease are somewhat different from those of the acute form. Here, too, infection takes place through a broken cutaneous surface, and leads to a superficial lymphangitis with nodular thickening of the lymphatics (farcy buds). The neighbouring glands soon become swollen and indurated. The primary lesion meanwhile inflames, suppurates, and, after breaking down, leaves a large, irregular ulcer with thickened edges and a foul, purulent or bloody discharge. The glands break down in the same way, and lead to wide destruction of skin, and the resulting sinuses and ulcers are exceedingly intractable. Secondary deposits in the subcutaneous tissue, the muscles, and other parts, are not uncommon, and the nasal mucous membrane may become involved. The disease often runs a chronic course, extending to four or five months, or even longer. Recovery takes place in about 50 per cent. of cases, but the convalescence is prolonged, and at any time the disease may assume the characters of the acute variety and speedily prove fatal.

The differential diagnosis is often difficult, especially in the chronic nodules, in which it may be impossible to demonstrate the bacillus. The ulcerated lesions of farcy have to be distinguished from those of tubercle, syphilis, and other forms of infective granuloma.

Treatment.—Limited areas of disease should be completely excised. The general condition of the patient must be improved by tonics, good food, and favourable hygienic surroundings. In some cases potassium iodide acts beneficially.

Actinomycosis

Actinomycosis is a chronic disease due to the action of an organism somewhat higher in the vegetable scale than ordinary bacteria—the streptothrix actinomyces or ray fungus.