human beings, infection with anthrax-bacilli may readily take place. It has further been maintained that such infection may take place even through the uninjured skin. Persons also are exposed to the danger of infection who are compelled to manipulate the remains of animals dead of anthrax, as, for instance, the hair and the hide, such as tanners and furriers. There is also a possibility that anthrax is conveyed to human beings by insects. Such individuals are exposed to the danger of alimentary or enterogenous anthrax as use the meat, the milk, the butter, or the cheese from animals suffering from anthrax. I have observed infection also through the intestine in a physician engaged in the study of anthrax-bacilli in the laboratory, where he took breakfast, which he unconsciously infected with anthrax-bacilli. Aërogenous or

FIG. 83.-Anthrax-bacilli from the subarachnoid space of the cerebellum, from a hostler dead of anthrax-carbuncle of the left forearm: stained by Gram's method; oil-immersion; magnified 1000 times (personal observation, Zurich clinic).

bronchogenous infection with anthrax-bacilli has, among other conditions, been observed in rag-establishments, the rags or the like being contaminated with anthrax-bacilli, which are inhaled with the dust generated as a result of the manipulations to which the rags are subjected. This variety of anthrax has been designated also rag-sorters' disease. Infection of one human being by another is possible, but probably occurs only rarely. Recovery from one attack of anthrax does not confer certain protection from subsequent attack.

Symptoms.-The local symptoms of anthrax vary in accordance with the character of the infection. In cases of inoculationanthrax or cutaneous anthrax, anthrax-carbuncle or anthrax-edema develops upon the external integument-alterations that occur at

the latest a week after infection. In the presence of anthraxcarbuncle there develops upon the skin, with slight prickling, sticking, and burning, a hard, red nodule, over which generally the epidermis is soon raised into a flabby, wrinkled vesicle filled with serous or hemorrhagic contents. The blister ruptures within a short time, but there forms about it a circle of new vesicles of similar character, and this process may be repeated several times in the further course of the disorder. Often, inflamed lymphatics pass from the cutaneous alterations described to the adjacent lymphatic glands in the form of red cords, and the glands are generally inflamed, swollen, and painful. The diseased portions of skin frequently acquire a blackish, gangrenous appearance. Anthraxedema frequently begins in the face, particularly in the eyelids. The skin is puffy, feels warm, and often exhibits a reddish erysipelatous discoloration. In places vesicular elevation of the epidermis takes place. The vesicles rupture and gangrenous alterations in the skin take place. Not rarely symptoms of anthrax-edema and anthrax-carbuncle occur in the same patient. To the local alterations of cutaneous anthrax symptoms of general infection become superadded in the course of about two days, particularly fever, progressive dyspnea, cyanosis, increasing coma and delirium, enlargement of the spleen, and exhaustion. Generally death occurs in the second week of the disease. Enterogenous or intestinal anthrax is attended with diarrhea, frequently with bloody stools, together with symptoms of general infection, while in cases of aerogenous or pulmonary anthrar pneumonie symptoms are most conspicuous among the local alterations. Intestinal and pulmonary anthrax may occur independently or in association with cutaneous anthrax.

Diagnosis. The diagnosis of anthrax is generally not difficult. Frequently the history will indicate contact with animals suffering from anthrax; but, above all, anthrax-bacilli should be looked for in the inflammatory foci of the skin, or, in the event of failure to find them, inoculation-experiments on animals (guineapigs, rabbits, and mice) should be undertaken, and after death has occurred the viscera should be examined for anthrax-bacilli.

Prognosis. The prognosis of anthrax is exceedingly grave. Most patients die, particularly if they come under medical treatment too late or only after the development of general infection.

Anatomic Alterations.-After death the body generally exhibits marked rigidity and cyanosis. In the internal viscera (heart, liver, kidneys, lungs, brain, etc.) extravasations of blood are frequently encountered. The lymphatic glands are increased in size and greatly distended with blood. The spleen and the liver are enlarged. Upon the intestinal mucous membrane nodules in process of breaking down are not rarely present-intestinal anthraxcarbuncle. In addition, the lymph-follicles of the intestinal mucous

membrane and the retroperitoneal glands are enlarged. Often the retroperitoneal connective tissue is inflamed and edematous. On microscopic examination, in addition to granular turbidity and fatty degeneration of parenchymatous cells of the various viscera, collections of anthrax-bacilli are found in the blood-vessels. In the capillaries of some organs (lungs, kidneys, liver) these accumulations often form connected casts, which give the impression of having resulted from mechanical as well as chemic-toxic influences. Anthrax-bacilli occur also in the lymph-spaces, particularly those of the brain (p. 542, Fig. 83). The blood exhibits hyperleukocytosis and diminished tendency on the part of the red corpuscles to form rouleaux. In the anthrax-carbuncle round-cell accumulations can be recognized, with hemorrhagic infiltrations and anthraxbacilli, the latter in part free, in part enclosed within cells. In addition, pyogenic cocci are generally present.

Treatment. In the prophylaxis great care especially will be required in dealing with animals suffering from anthrax. Meat and milk and the secondary products of the latter from animals suffering from anthrax should not be used. The hide and the hair should first be sterilized before they are sold to merchants. Excision or cauterization of an anthrax-carbuncle would be useful only if general symptoms were not already present. Even under such circumstances many surgeons advise rather affusions of mercuricchlorid solution or inunctions of mercurial ointment. Internally stimulants should be administered. In the treatment of intestinal anthrax quinin, calomel, and intestinal infusions of saline solution have been recommended.

GLANDERS.

Etiology. The cause of glanders is the bacillus of glanders (Fig. 84) discovered by Loeffler and Schütz (1882), who succeeded in growing glanders-bacilli in pure culture and in inoculating animals successfully with them. Glanders occurs most frequently in horses, and all persons are exposed to the danger of infection who come in contact with animals suffering from the disease, particularly hostlers, veterinarians, and horse-slaughterers. Infection generally takes place from the entrance into open cutaneous wounds of discharges from glanders-lesions or of blood-inoculationglanders. Infection is believed to be possible even through the uninjured skin. Alimentary glanders, induced by the use of the meat of animals suffering from glanders, probably is exceedingly Whether aerogenous infection takes place through inhalation of the air in stables containing animals suffering from glanders, has not been demonstrated with certainty. In isolated instances. transmission from one person to another has been observed.

rare.

Symptoms and Prognosis.-The symptoms of glanders,

which develop most frequently within from three to five days after inoculation, resemble those of septicopyemia, and accordingly as the disease pursues a course covering from two to four or from four to twelve weeks or several months, or even years, a distinction has been made between acute, subacute, and chronic glanders. Chronic glanders is not rarely attended with acute exacerbations that frequently terminate fatally. Among local alterations, nodules and infiltrates occur upon the external integument, undergoing ulceration and exhibiting but slight tendency to cicatrization. Frequently, partial cicatrization takes place; but, on the other hand, the destructive process continues to extend in other situations. This fact explains the designation worm that is sometimes applied to glanders. The number of glanders-nodules is variable.

In cases of chronic glanders new nodules continue to appear for years. In the vicinity of glanders-nodules the skin frequently exhibits erysipelatous and erythematous alterations. Inflamed lymphatics also are not rarely observed to arise from them. Adjacent lymphatic glands are often swollen and not rarely also undergo suppuration. Occasionally the skin is covered with large and small vesicles, suggestive of pemphigus, impetigo, and cethyma. Frequently the muscles are the seat of nodules, infiltrates, and abscesses. At times purulent arthritis develops. Glanders-nodules and glanders-infiltrates form also upon the mucous membranes, subsequently undergoing purulent breaking down, and as a result giving rise to ulcers of the mucous membrane of considerable extent. The nasal mucous membrane is involved with especial

frequency. Under such circumstances purulent and bloody discharges take place from the nose, and there is, in addition, pain, particularly in the frontal sinuses. The laryngeal mucous membrane likewise is frequently the seat of the lesions of glanders. Finally, abscesses form also in the internal viscera (lungs, myocardium, liver, kidneys, spleen, etc.) resulting from the breaking down of glanders-nodules. General infection is indicated by fever, which often is interrupted by chills, and by progressive loss of strength, as a result of which death generally occurs. Although recovery from glanders does take place, this is rather the exception, so that the prognosis is always grave.

Diagnosis.-Glanders can be recognized with certainty only by means of bacteriologic methods. In the first place, discharges and blood should be examined for glanders-bacilli, and in doubtful cases discharges should be introduced into the abdominal cavity of guinea-pigs, in which, in case the disease be glanders, inflammation and suppuration of the testicle soon develop. Glandersbacilli possess readily recognizable peculiarities when cultivated upon potatoes. On the second or the third day pure cultures upon this medium form an amber-yellow coating, which in the course of eight days becomes coppery-red and surrounded by a greenish zone. The clinical picture of glanders might be confounded, in addition to that of septicopyemia, also with that of tuberculosis and of syphilis.

Anatomic Alterations.-Glanders-nodules and glandersinfiltrates consist of aggregations of round cells, which exhibit in marked degree a tendency to purulent disintegration and to caseation. They may occur in any viscus, even in cartilage and in bone.

Treatment.-In addition to surgical treatment of abscesses and ulcers, inunctions of mercurial ointment and the administration of potassium iodid have especially been recommended.

ACTINOMYCOSIS (RAY-FUNGUS DISEASE).

Etiology.-Actinomycosis is due to the activity of the rayfungus-actinomyces-which is included among fission-fungi, and belongs to the variety eladothrix. It occurs especially upon grasses, wheat, corn, and beards. It gains entrance into the human body either from the mouth or through inhalation. Inoculation through splinters of wood upon which the ray-fungus is lodged is also known to occur. The danger of infection through carious teeth is incurred especially by such persons as indulge in the practice of introducing blades of grass between the teeth in walking in the open air.

Symptoms and Diagnosis.-The ray-fungus gives rise to