BRONCHIAL SNTHRAX.] By THEODORE SHENNAN, M.D., Patlzoloyist ; and JAMES MILLER, M.D.,

Assistant Pathologist, Edinburgh Royal Infirmary.

From the PathobyicaE Deparlme?it, EdiTaburgh R q a l Iri$rmary.

(PLATE XXXVIII.)

AT the present day comparatively few opportunities are afforded of studying fatal cases of bronchial anthrax, even in wool-manufacturing districts.

The case which me wish to describe, in addition to the circunistance that no relationship t o the wool-inanufactiiring industry can be traced, presents some unusual features which render it specially interesting.

Bronchial anthrax, wool-sorters’ disease, pulmonary anthrax, was unknown in this country prior to the year 183’7, when alpaca (from Peru) and mohair (from the Lake Van district of Asia Minor) first’ came into use in the factories in Bradford. Soon it was noticed by the workmen themselves that the sorting of certain varieties of wool was attended with great risk, and in 1846 Corrie of Thornton, h l ‘ lach lan of Shelf, and others determined exactly the kinds of fleeces which were to blame, but the actual causes of the disease escaped observation (Bell, 1 8 8 0).

Samuel Lodge (senior), during the seventies, conducted post-mortem esnuiinations on several fatal cases, and described in the pulmonary exudate “ delicate, finely segmented hairs,” which he took to be the ddbris of wool (ref. Lodgc, jun., 1890).

J. H. Eel1 of Bradford (1880), early in 1878, read a paper in which he declared that “ Wool-sorters’ disease mas a septicmiia, caused by inhalation of a septic poison (spores, bacteria, or other living organism) produced by the decomposition of animal matter within the bales of wool.” In February 1878, lh. Eddison of Lee& suggested to Bell that the disease ‘*might be splenic frver, caused by the now famous Bacillus antiwacis.” Bell did not recognise the bronchial condition as primary, thougli from the bronchial exudate he cultivated micro-organisms which he believed to correspond to the B. anthracis. In the cases which canie under his observation the incubation stage varied from seventeen hours to five days.

It was reserved for Spear (1880) and Greenfield (1880-81), who were sent t o Ersdford by the Local Government Board to investigate the disease, to

Received April 26, 1910.

BRONCHIAL ANTHRAX. 557

fully deinonstrate the actual pathogenetic agent, and its relationship to the disease.

Greenfield concluded that the affection was, in most cases, primarily a local condition affecting the bronchi and the bronchial glands. The disease was most marked near the bifurcation of the trachea and in the large bronchi, rarely reaching beyond the second division of these. It presented itself as a diffuse mycosis of the mucous and submucous tissues, with a variable degree of catarrh and ecchymosis. It extended either directly into the mediastinum, causing a mediastinal cellulitis, or by may of the bronchial glands, producing in them intense lymphadenitis and hamorrhage. He constantly observed what he considered serous effusion into the pleural sacs, partly inflammatory in origin, but probably mainly dependent on the acute obstruction to absorp- tion through the mediavtinal glands. I n SOIUC cases he found in the bronchi, “ what may be termed multiple malignant pustules.” Early broncho-pneumonic processes were occasionally seen, but these never reached a high degree. HEmorrhagic infarcts mere occasionally found. The epithelium of the bronchi was affected only in the later stages, when its nutrition was interfered with by the processes which were taking place in the tissues immediately subjacent. A layer of catarrhal exudate mixed with blood was frequently found upon the surface of the mucous membrane. The bacilli were found in the lymphatic vessels surrounding the dilated blood vessels of the submucous coat, never within them, and only occasionally within minute blood vessels. The affected lymphatics were traced to the bronchial lymph glands, and also into the lung. Inflammation of the pleura was never found. In concluding his report to the Local Government Board, Greenfield stated that a bronchial infection, though very probable, was not conclusively proved. That he believed this to be the case is, however, yery evident from perusal of his subsequent papers, in which a very complete description of the disease is given, to which little of essential value has been added by more recent investigators.

On the Continent of Europe also, attention has been directed for some years to the possibility of anthracial infection by way of the air passages.

Eppinger (l894), whose investigation of the subject of the hroncho- pulmonarg anthrax of ragpickers or sorters in paper mills (Hadernkrankheit) was completed in 1888, gives a review of the work which had been done on the Continent in connection with t h a t disease. He refers to papers by Klob, Karsten and Langer, Schlemmer, and others, which appeared during the seventies. These observers did not recognise the true nature of the septic poison.

Kundrat (1877), in the blood, in the pleural effusion, in infiltrated parts of the lungs, and in plaques on the mucous membranes of the trachea, bronchi, stomach, and duodenum, found bacteria which, from microscopic examination alone, he believed to be anthrax bacilli.

Frisch (1878) experimented with blood from a dog which had died after inoculation with human blood from a fatal case of rag-pickers’ disease, which had been examined by Schlemmer. Rabbits inoculated in their corneae, or subcutaneously with the dog’s blood, died in from eighteen to twenty-two houw. Micro-organisms were recovered, the behaviour of which in hanging-drop cultivations corresponded with that of the anthrax bacillus as described by Koch.

Paltauf (1888) in 1882 experimented with material from two cases, one of which had been examined by Kundrat. He inoculated mice, and concluded that he was dealing with an anthrax infection. He discusses the literature and analyses his own investigations in very full and elaborate detail..

Samuel Lodge, jun. (1890), described five cases which had come under his own observation, and gave what is practically a summary of the conclusions arrived a t by Spear and Greenfield, without adding anything as a result of his own work.

558 THEODORE SHENNAN AND JAMES MILLER.

Eppinger (l894), during 1885-86, investigated eight cases, from seven of which he separated pure cultures of bacilli identical with the anthrax bacillus. The eighth case was examined forty-eight hours after death, and the inoculated media became overgrown with the B. proteus Zenkeri. Eppjnger’s monograph gives elaborate details of his investigations which fully conhrmed Greenfield’s results, and conclusively proved that the rag-pickers’ disease of Austria was identical with the wool-sorters’ disease of England.

I n Eppinger’s series of cases, lobular pneumonia was observed more fre- quently than in the English cases, and he believed that the hsmorrhagic changes, so constantly observed in these cases, were not essential features of the disease. Apart from these and other slight differences, he adds little of importance to Greenfield‘s classical account of the disease.

THE AUTHORS’ CASE.

The special interest attaching to our own case is the absence of any discoverable relationship to the ordinary sources of infection.

The patient was admitted, on Noveinber 15, 1 9 0 9 , in an almost moribund condition, to the wards in the Edinhrgh Royal Infirmary under the charge of Professor Sir Thomas R. Fraser, to whom our cordial thanks are due for permission to publish the case, and to make use of the personal history and clinical details collected by his house physician, Dr. A. Gibson.

HISTORY (obtained in part after the death of the patient).-The patient was a male, zt. 42, who was employed as a clerk with a firm of iron-founders.

During the days immediately preceding his illness he was entirely engaged in clerical work within the office. His firm were engaged on the new Edinburgh slaughter-houses, but as yet no animals had been killed there. The nearest place where hides, etc., are used, is at some works about .one mile distant. The patient’s home was in the opposite direction. According to his wife’s statements, he had never any direct personal association with butchers, slaughter-houses, wool or hair.

The evenings of the 9th and 10th November were spent quictly at home. On the evening of the 11th November he complained of having a slight cold.

Next morning he had for breakfast a portion of a black pudding.1 Soon afterwards he felt sick, and vomited. He went to work as usual, but the severe vomiting still continued. At dinner he ate some tripe, obtained from the same shop. I n the evening he returned home an hour sooner than usual, because he felt “ done ” and sick. The vomiting had ceased. Retiring to bed early, he did not sleep well, felt cold, shivered, and was very thirsty.

On the 13th he rose at 7 a.m., partook of very little breakfast, and went t o work feeling very ill. He had a slight cough with wheezing respiration, but no expectoration. He returned home early, and went t o bed at 2 p.m., but rose during the evening. He sat by the fire, wheezing and coughing, bu t not to an extreme degree. During the night, on rising to obtain a drink, he fainted.

Next morning (14th) he complained of pain between the shoulders, worse on coughing. There was no vomiting.

On the morning of the 15th he was SO weak that he could hardly move. He drank a little milk, but it was at once rejected. He suffered from head- ache, and later in the day was seized with severe abdominal pain and intellse dyspncea. His mental condition was unaffected. A diagnosis of capillary

A “black ” pudding is it sausage containing chiefly blood and oatmeal, with chopped onions or leeks.

No dyspncea was observed.

BR ONCUIAL ANTHRAX. 559

bronchitis was made by his medical attendant, and his condition being now extremely serious, he was sent to the Royal Infirmary, arriving there a t 10.30 p.m.

On adinission he looked like a case of profound septic intoxication. Intense collapse was the striking feature. There was no jaundice, dropsy, or cyanosis, and no abdominal pain on palpation. The pulse was almost imperceptible,-82 per minute,-and the heart sounds were obscured by the breath sounds. The temperature was subnormal. There was marked rattling of mucus in the throat ; many moist sounds were audible, especially over the bases of the lungs, where the percussion note was dull. A blood count revealed :L leucocytosis of 17,800 per cubic niillimetre.

He died at 2.40 next morning, about four hours after admission. THE PosT-Monmnf EXAMINATION was conducted nine hours after death, The body was that of a man of medium height, well developed, and

fairly well nourished. Rigor mortis was absent in the upper, well marked in the lower limbs.

Post-mortem lividity was marked on the posterior surfaces. There was no unusual cyanosis of the extremities or face.

The neck was somewhat fuller than normal, and the cervical veins were filled with dark fluid blood.

On opening the thorax the mediastinal tissues were extremely axlematous, and iufiltrated with blood, particularly posteriorly, beneath the arch of the aorta, along the descending thoracic aorta, the trachea and bronchi, and over the adjacent portions of visceral pleura, particularly over the right upper lobe. The lymphatic glands about the bifurcation of the trachea were greatly enlarged and infiltrated with blood, so that they resembled masses of blood clot.

The pericardial sac contained about half an ounce of yellowish serous fluid.

Firm adhesions existed between the pleural surfaces on the left side, and these were edematous. Adhesions were also present in the right pleura, but these were easily broken down.

The lungs (Plate XXXVIII.) were edematous, deeply congested, partly collapsed, and contained small areas, apparently of hamorrliagic nature, whlch were rather more resistant than the rest of the lung. The trachea contained hEemorrhagic exudate.

A deeply congested area, mottled with hzmorrhages, was found a t the bifurcation of the trachea, extending upwards for about 13 in. and extending downwards into the bronchi past their first divisions. I n the main bronchi the hmnorrhagic effusion became uniform, and just below the bifurcation, in the left bronchus, a small greyish-yellow patch, of the size of a hemp-seed, was observed, evidently of necrotic nature. The hsmorrhage extended outwards between the cartilages, causing these to stand out distinctly upo~l a dark red ground. Within the lungs the hemorrhage extended along the septa. Outside the wall of the left bronchus there was a spongy pale grey mass, which on microscopic examination was found to consist, for the most part, of fibrinous exudate, crowded with bacilli. Films prepared from the exudate in the lumen contained abundant anthrax bacilli often in clumps, leucocytes, cast-off ciliated epithelial cells, and red blood corpuscles.

MICROSCOPICAL EXAMINATION OF SECTIONS showed that in parts the more superficial epithelial cells were cast of, but catarrh was by no means a prominent feature. Numerous bacilli were found between the epithelial cells, and diffusely scattered throughout the hsmorrhagic areas in the submucous coat. The walls of the engorged blood vessels were in many cases visible in this situation, but the outlines of the lymphatics could not be defined. Occasion- ally bacilli were observed in clumps, in relation to which there was some leucocyte infiltration, Abundant bacilli were found between the cartilages,

The surrounding loose connective tissue was also infiltrated with blood.

560 THEODORE SHZW"AJ AND JAMES MILLER.

extending outwards in the lymphatic spaces, in the septa, and in the adven- titia of the dilated blood vessels. They were followed outwards to within an inch :ind a half of the plcura, being especially evident in the hmnorrhagic areas noted in the preliminary examination of the lungs. I n these areas the blood vessels were engorged, some of the larger of them containing sninll leuco- cyte thrombi, and the vesicles were filled with coagulated nlbuniinous fluid. No bacilli were found within the blood vessels. Clumps were constantly observed in relation to collections of carbon pigment in the septa and in the outer coats of the bronchi, being manifestly contained within the lymphatics. Soiie were found in the deep layer of the pleura, or in the septa. in its immeilinte vicinity.

In the case of the distended venous radicles near the root of the liing, bacilli mere occasionally observed as if passing through the malls, but this appearance may have been artificial.

The lymphatic glands at the root and along the bronchi and trachea mere to a great extent disorganised, and little but blood was to be seen in sections. Bacilli were present in large numbers, and were especially Frouped at the periphery, being evidently collected in the sinuses in that situation.

The heart showed no evident pathological change, and tho myocardium was firm.

The peritoneum was cormal, and the fluid in the cavity was not increased. The stomach was the seat of atrophic gastric catarrh, and was congested,

but there were no hsmorrhages or erosions of the mucous membrane. N o evident changes were observed along the htestinal tract, and the

abdominal lymphatic glands were not greatly enlarged. The spleen was moderately enlarged and soft, and the Malpighian bodies

were prominent. The liver and the kidneys showed marked cloudy swelling. The brain and cerebral meninges were not excessively congested ; there

was no haemorrhagic infiltration, but the white matter was extremely cadematous.

The naked-eye pathological changes observed at the post-mortem examination indicated that death was the result of a severe toxemia, and the mediastinal hmnorrhages which had clearly not originated from rupture of a large vessel suggested that the toxmnia was the result of an acute virulent bacterial infection. Media were inoculated from the disorganised bronchial glands, and upon these pure growths developed of a bacillus identical biologically, tinctorially, and morphologically, with the anthrax bacillus. Inoculation of a mouse with n portion of one of the primary agar cultures resulted in the death of the animal within thirty-six hours. The bacilli were recovered from the heart. blood of the mouse after death.

The naked-ey c and microscopic appearances above described clearly indicate a local primary anthracial infection at the bifurcation of the trachea, and in the larger bronchi, with extension by way of the lymphatics to the tracheal and bronchial lymphatic glands, and to the lung tissue.

The features of the case closely correspond with those. of the cases of wool-sorters' disease described by Greenfield.

While there is no room for doubt as to the nature of the case, we still remain in the dark as to the origin and the channel of infection.

BRONCfllAL ANTNRAX. 561

As has already been indicated, no relationship can be traced to the ordinary sources of infection, and the only suggestion we would make is that the black pudding, which formed part of the patient’s breakfast on the morning of the 12th November, four days before death, may have been infected with anthrax bacilli. It is possible, however, that the slight cold noted on the previous evening may have been the first symptoms of a bronchial infection, and that the disease had already commenced before the black pudding had been consumed.

Presumably, howeFer, the man felt in approximately his ordinary health on the morning of the 12th November, and the first serious phenomena were the sickness and severe vomiting, which set in shortly after breakfast. One cannot exclude the possibility of particles of the pudding containing spores of anthrax bacilli having passed, while being rejected, either directly into the trachea or into the upper air passages, from which they were subsequently inhaled, thus reproducing the conditions causing infection in wool-sorters.

The case also illustrates the importance which should be attached to diffuse capillary hzemorrhages, particularly in unusual situations, such as the mediastinal tissues and serous membranes, as indicating virulent bacterial infections. This fact might well be elevated to the position of an axiom in pathological teaching. I t is manifestly necessary to exclude the petechial hsmorrhages which occur in asphyxiation in different forms of gas poisoDing ; those also which are associated with chronic disease of blood vessels, with the hsmorrhagic diatheses, with mechanical injuries, and with poisoning with metallic salts.

BELL, J. H. . . . . .

EPPINQER, HAM . . . FRISCE . . . . . . .

GREENFIELD, Ur. S. . .

. . . ,,

. . . Y,

KUNDRAT . . . . . . 3 7 4 L OF PATH.-VOL. XIV.

REFERESCES.

r r On Woolsorters’ Disease,” Lancet, London, 1880, vol. i. pp. 871, 909; Brit. Med. Journ., London, 1881, vol. i. p. 915.

“ Die Hadernkrankheit,” Jena, 1894. “ Experimentale Untersuchungen iiber die Hadern-

krankheit,” Wien. Med. Wchnschr., 1878, S S . 50, 76, 125.

‘‘ Supplementary Report on the Woolsorters’ Disease in the Bradford District,” “ Eleventh Annual Report of the Local Government Board,” London, 1881-82, pp. 207-226.

“ Lectures on some Recent Investigations into the Pathology of Infective and Contagious Diseases,” Lancet, London, 1880, vol. i. pp. 83, 355, 517, 631, 865, vol. ii. p. 41.

6‘ Further Investigations on Anthrax and Allied Diseases in Man and Animals,” Lancet, London, 1880, vol. ii. 965 ; 1881, vol. i. pp. 3, 91, 163.

ref. Eppinger.

562 BRONCHIAL ANTHRAX.

LODQE, SAMUEL (FILB). . “La Maladie des Trieurs de Laine (Charbon broncho-pulmonaire),” Arch. de. naQd. expir, et d’anat. path., Paris, 1890, tome ii. p. 759.

PALTAUF, R. . , . . . “Zur Aetiologie der Hadernkrankheit,” Wien. Klin. Wchnsckr., 1888, Bd. i. SS. 382, 403, 419, 438, 456, 480, 499, 520, 533.

SPEAR, J. . . . , . , “Report on the so-called Woolsorters’ Disease (including Preliminary Pathological Report by Greenfield),” ‘(Tenth Annual Report of the Local Government Board,” London, 1880 -81, pp. 66-135.

DESCRIPTION OF PLATE XXXVIII.

Larynx, trachea, with left lung and its bronchi, from a case of bronchial anthrax.

JOURNAL OF PA'l'IIOI.OGY.-VoL. XIV. PLATE XXXVIII ,