Manual of Surgery Volume I Part 14

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 a.s.sumes a pyaemic type. The pulse becomes rapid and weak. The tongue is dry and brown. There is profuse sweating, alb.u.minuria, 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 septicaemia or pyaemia. 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, const.i.tuting 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 b.l.o.o.d.y 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 a.s.sume 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 pota.s.sium 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_.

[Ill.u.s.tration: FIG. 30.--Section of Actinomycosis Colony in Pus from Abscess of Liver, showing filaments and clubs of streptothrix actinomyces. 400 diam. Gram's stain.]

_Etiology and Morbid Anatomy._--The actinomyces, which has never been met with outside the body, gives rise in oxen, horses, and other animals to tumour-like ma.s.ses composed of granulation tissue; and in man to chronic suppurative processes which may result in a condition resembling chronic pyaemia. The actinomyces is more complex in structure than other pathogenic organisms, and occurs in the tissues in the form of small, round, semi-translucent bodies, about the size of a pin-head or less, and consisting of colonies of the fungus. On account of their yellow tint they are spoken of as "sulphur grains." Each colony is made up of a series of thin, interlacing, and branching _filaments_, some of which are broken up so as to form ma.s.ses or chains of _cocci_; and around the periphery of the colony are elongated, pear-shaped, hyaline, _club-like bodies_ (Fig. 30).

Infection is believed to be conveyed by the husks of cereals, especially barley; and the organism has been found adhering to particles of grain embedded in the tissues of animals suffering from the disease. In the human subject there is often a history of exposure to infection from such sources, and the disease is said to be most common during the harvesting months.

Around each colony of actinomyces is a zone of granulation tissue in which suppuration usually occurs, so that the fungus comes to lie in a bath of greenish-yellow pus. As the process spreads these purulent foci become confluent and form abscess cavities. When metastasis takes place, as it occasionally does, the fungus is transmitted by the blood vessels, as in pyaemia.

_Clinical features._--In man the disease may be met with in the skin, the organisms gaining access through an abrasion, and spreading by the formation of new nodules in the same way as tuberculosis.

The region of the mouth and jaws is one of the commonest sites of surgical actinomycosis. Infection takes place, as a rule, along the side of a carious tooth, and spreads to the lower jaw. A swelling is slowly and insidiously developed, but when the loose connective tissue of the neck becomes infiltrated, the spread is more rapid. The whole region becomes infiltrated and swollen, and the skin ultimately gives way and free suppuration occurs, resulting in the formation of sinuses. The characteristic greenish-grey or yellow granules are seen in the pus, and when examined microscopically reveal the colonies of actinomyces.

Less frequently the maxilla becomes affected, and the disease may spread to the base of the skull and brain. The vertebrae may become involved by infection taking place through the pharynx or sophagus, and leading to a condition simulating tuberculous disease of the spine. When it implicates the intestinal ca.n.a.l and its accessory glands, the lungs, pleura, and bronchial tubes, or the brain, the disease is not amenable to surgical treatment.

_Differential Diagnosis._--The conditions likely to be mistaken for surgical actinomycosis are sarcoma, tubercle, and syphilis. In the early stages the differential diagnosis is exceedingly difficult. In many cases it is only possible when suppuration has occurred and the fungus can be demonstrated.

The slow destruction of the affected tissue by suppuration, the absence of pain, tenderness, and redness, simulate tuberculosis, but the absence of glandular involvement helps to distinguish it.

Syphilitic lesions are liable to be mistaken for actinomycosis, all the more that in both diseases improvement follows the administration of iodides. When it affects the lower jaw, in its early stages, actinomycosis may closely simulate a periosteal sarcoma.

[Ill.u.s.tration: FIG. 31.--Actinomycosis of Maxilla. The disease spread to opposite side; finally implicated base of skull, and proved fatal.

Treated by radium.

(Mr. D. P. D. Wilkie's case.)]

The recognition of the fungus is the crucial point in diagnosis.

_Prognosis._--Spontaneous cure rarely occurs. When the disease implicates internal organs, it is almost always fatal. On external parts the destructive process gradually spreads, and the patient eventually succ.u.mbs to superadded septic infection. When, from its situation, the primary focus admits of removal, the prognosis is more favourable.

_Treatment._--The surgical treatment is early and free removal of the affected tissues, after which the wound is cauterised by the actual cautery, and sponged over with pure carbolic acid. The cavity is packed with iodoform gauze, no attempt being made to close the wound.

Success has attended the use of a vaccine prepared from cultures of the organism; and the X-rays and radium, combined with the administration of iodides in large doses, or with intra-muscular injections of a 10 per cent. solution of cacodylate of soda, have proved of benefit.

MYCETOMA, OR MADURA FOOT.--Mycetoma is a chronic disease due to an organism resembling that of actinomycosis, but not identical with it.

It is endemic in certain tropical countries, and is most frequently met with in India. Infection takes place through an abrasion of the skin, and the disease usually occurs on the feet of adult males who work barefooted in the fields.

_Clinical Features._--The disease begins on the foot as an indurated patch, which becomes discoloured and permeated by black or yellow nodules containing the organism. These nodules break down by suppuration, and numerous minute abscesses lined by granulation tissues are thus formed. In the pus are found yellow particles likened to fish-roe, or black pigmented granules like gunpowder. Sinuses form, and the whole foot becomes greatly swollen and distorted by flattening of the sole and dorsiflexion of the toes. Areas of caries or necrosis occur in the bones, and the disease gradually extends up the leg (Fig. 32).

There is but little pain, and no glandular involvement or const.i.tutional disturbance. The disease runs a prolonged course, sometimes lasting for twenty or thirty years. Spontaneous cure never takes place, and the risk to life is that of prolonged suppuration.

If the disease is localised, it may be removed by the knife or sharp spoon, and the part afterwards cauterised. As a rule, amputation well above the disease is the best line of treatment. Unlike actinomycosis, this disease does not appear to be benefited by iodides.

[Ill.u.s.tration: FIG. 32.--Mycetoma, or Madura Foot. (Museum of Royal College of Surgeons, Edinburgh.)]

DELHI BOIL.--_Synonyms_--Aleppo boil, Biskra b.u.t.ton, Furunculus orientalis, Natal sore.

Delhi boil is a chronic inflammatory disease, most commonly met with in India, especially towards the end of the wet season. The disease occurs oftenest on the face, and is believed to be due to an organism, although this has not been demonstrated. The infection is supposed to be conveyed through water used for was.h.i.+ng, or by the bites of insects.

_Clinical Features._--A red spot, resembling the mark of a mosquito bite, appears on the affected part, and is attended with itching. After becoming papular and increasing to the size of a pea, desquamation takes place, leaving a dull-red surface, over which in the course of several weeks there develops a series of small yellowish-white spots, from which serum exudes, and, drying, forms a thick scab. Under this scab the skin ulcerates, leaving small oval sores with sharply bevelled edges, and an uneven floor covered with yellow or sanious pus. These sores vary in number from one to forty or fifty. They may last for months and then heal spontaneously, or may continue to spread until arrested by suitable treatment. There is no enlargement of adjacent glands, and but little inflammatory reaction in the surrounding tissues; nor is there any marked const.i.tutional disturbance. Recovery is often followed by cicatricial contraction leading to deformity of the face.

The _treatment_ consists in destroying the original papule by the actual cautery, acid nitrate of mercury, or pure carbolic acid. The ulcers should be sc.r.a.ped with the sharp spoon, and cauterised.

CHIGOE.--Chigoe or jigger results from the introduction of the eggs of the sand-flea (_Pulex penetrans_) into the tissues. It occurs in tropical Africa, South America, and the West Indies. The impregnated female flea remains attached to the part till the eggs mature, when by their irritation they cause localised inflammation with pustules or vesicles on the surface. Children are most commonly attacked, particularly about the toe-nails and on the s.c.r.o.t.u.m. The treatment consists in picking out the insect with a blunt needle, special care being taken not to break it up. The puncture is then cauterised. The application of essential oils to the feet acts as a preventive.

POISONING BY INSECTS.--The bites of certain insects, such as mosquitoes, midges, different varieties of flies, wasps, and spiders, may be followed by serious complications. The effects are mainly due to the injection of an irritant acid secretion, the exact nature of which has not been ascertained.

The local lesion is a puncture, surrounded by a zone of hyperaemia, wheals, or vesicles, and is a.s.sociated with burning sensations and itching which usually pa.s.s off in a few hours, but may recur at intervals, especially when the patient is warm in bed. Scratching also reproduces the local signs and symptoms. Where the connective tissue is loose--for example, in the eyelid or s.c.r.o.t.u.m--there is often considerable swelling; and in the mouth and fauces this may lead to dema of the glottis, which may prove fatal.

The _treatment_ consists in the local application of dilute alkalies such as ammonia water, solutions of carbonate or bicarbonate of soda, or sal-volatile. Weak carbolic lotions, or lead and opium lotion, are useful in allaying the local irritation. One of the best means of neutralising the poison is to apply to the sting a drop of a mixture containing equal parts of pure carbolic acid and liquor ammoniae.

Free stimulation is called for when severe const.i.tutional symptoms are present.

SNAKE-BITES.--We are here only concerned with the injuries inflicted by the venomous varieties of snakes, the most important of which are the hooded snakes of India, the rattle-snakes of America, the horned snakes of Africa, the viper of Europe, and the adder of the United Kingdom.