PATHOLOGICAL REPORT ON A CASE OF RABIES IN A

WOMAN."

By JOHN R. MOHLER, A. M., V. M. D.,

Chief of Pathological Division, Bureau of Animal Industry.

GENERAL REMARKS.

While walking through a vacant lot on February 11, 1902, Mrs. J., colored, of Washington, D. C., was fiercely attacked and severely bitten on the right forearm, near the inner canthus of the left eye, and on the left frontal eminence by a stray collie dog. Eighteen days later the woman complained of a general malaise and pains in the cicatrized wounds of the head, which rapidly grew more severe, necessitating the services of a physician. Upon the latter's advice the patient. was removed on the following day to Freedmen's Hospital, where the case was diagnosed as "suspected rabies." On the afternoon of March 3 the writer visited the hospital, on the invitation of Dr. William C. Woodward, District health officer, to whom we are indebted for the kindness of having brought this case to our attention. The patient was found in an extremely nervous condition, having an excessive feeling of fear and uneasiness. The eyes were staring, and a general expression of anxiety pervaded the countenance of the individual. The mind, however, was clear and no efforts at violence were made. When interviewed as to the cause of the scars on her head and forearm, she lightly replied: "Oh, a dog bit me there some weeks ago, but they are all right now."

From time to time reflex spasms involving the muscles of deglutition were noticed, causing a clutching at the throat and difficult breathing during the attack. These rapidly became more generalized, and in a few hours also involved the respiratory muscles, causing extreme dyspnea. Attempts at vomiting would then occur, but no evacuations followed. Contrary to the usual run of cases, the patient accredited these symptoms to indigestion and had not the slightest suspicion of the true nature of her condition, thus disproving the idea that the nervousness and fear usually seen in the early stages of rabies in the human subject are due to the natural dread of the disease and appre

a This report was prepared for filing in the District Health Office, together with the records furnished by the attending physician, the hospital pathologist, and the resident physician. For this reason only those portions of the history and clinical symptoms that were brought to my attention will be given at this time.-J. R. M.

hension of the consequence rather than to organic changes in the central nervous system.

During the night these symptoms became more aggravated, and spasms followed one another more rapidly, causing grave delirium. The patient finally became violent, and necessitated the adoption of forcible measures to keep her under control. Death occurred on the following day, March 4, twenty-one days after the bites had been inflicted, and a postmortem examination was made by the hospital pathologist at noon. The cadaver showed a well-developed female about twenty-eight years of age. The heart, lungs, spleen, liver, kidneys, stomach, and intestines were apparently normal. The meninges of the brain were somewhat injected and the brain substance slightly edematous. Macroscopic examination of these tissues failed to reveal any pathological lesions which could be held accountable for the symptoms which resulted in death.

Following the necropsy, the medulla oblongata, the superior portion of the spinal cord, and the right plexiform ganglion of the pneumogastric nerve were removed under aseptic precautions, placed in sterile flasks, and brought to the Pathological Division of the Bureau of . Animal Industry for an investigation of rabies.

A series of culture media consisting of peptonized beef bouillon, slant and stab agar, gelatin, blood serum, and fermentation tubes of saccharose, lactose, and glucose were inoculated from the center of the medulla oblongata, after searing the surface and making a transverse incision with a flamed knife. The absence of microorganisms was demonstrated by the failure of any of these various media to show' fertility.

HISTOLOGICAL EXAMINATION.

A histological examination of the plexiform ganglion was made for the purpose of determining whether the lesions described by Van Gehuchten and Nelis" as typical of rabies were present. After fixation in a 10 per cent solution of formalin, it was transferred to 95 per cent alcohol, then to absolute alcohol, each for a period of two hours, placed in equal parts of alcohol and chloroform for one hour, chloroform one hour, chloroform and paraffin one hour, and paraffin six hours. The sections were stained in hematoxylin and eosin, Unna's polychromatic blue, and Van Gieson's picric acid and acid fuchsin. On microscopic examination, instead of finding the ganglion composed of the normal ganglionic cells surrounded by their capsules, consisting of a single layer of endothelial cells and situated in the interstitial neurogliar tissue (see Pl. I, fig. 1), a very different picture was observed. The large majority of the ganglion cells were found to be affected, but in varying degrees of intensity. (See Pl. I, fig. 2.) a Diagnostic histologique de la rage, A. Van Gehuchten and C. Nelis, Annales de Médecine Vetérinaire, v. 49, Mai 1900, pp. 243-252.

The principal change observed was the extensive proliferation of the layer of endothelial cells of the capsule, although the leucocytic infiltration of the sustentacular tissue was also well marked. This proliferation and ingrowth of new cells from the capsule had invaded the pericellular spaces and the protoplasm of a number of the nerve cells and produced pressure on, and consequent atrophy of, the cytoplasm, thus leaving the nucleus surrounded by several layers of proliferated endothelial cells. In a few ganglion cells the pathological process had extended still further, causing a complete obliteration of the nucleus as a result of the invasion of the entire capsule by a dense mass of cells, causing these areas to assume a decidedly sarcomatous aspect. In other cells the changes were but slightly marked, the only observable alteration being an increase in the number of endothelial cells lining the capsule, the faint cell nuclei, or the poorly stained cellular protoplasm.

A portion of the medulla in the region of the apex of the corpora pyramidalia was fixed in the usual manner. After thorough dehydration in absolute alcohol the tissue was placed in a thin solution of celloidin for twelve hours, then into thick celloidin for an equal length of time. Sections were stained with alum hematoxylin and eosin, Van ́ Gieson's picric acid and acid fuchsin, and Nissil's stains. The lesions observed were in part similar to the description given by Babes," but not so extensive. A well-marked accumulation of embryonic cells about the blood vessels in the perivascular lymph spaces was seen and a leucocytic infiltration also observed surrounding some of the ganglion cells. These perivascular and periganglionic cell accumulations have been termed by Babes the "rabic tubercles," and are considered by him as diagnostic. Some of the blood vessels appeared dilated with an extensive proliferation of connective tissue cells of the adventia. The changes of the ganglion cells were not so marked. Disseminated swelling and disintegration of the Nissil bodies (chromatolysis) were present in some cells, while in others only tumefaction could be seen, with the cytoplasm taking the stain but feebly. In teased preparations the processes of the nerve cells appeared more or less distorted and atrophied, and vacuolation was occasionally observed. The latter was also manifest at times in the cells of the neuroglia.

INOCULATION EXPERIMENTS.

Within three hours from the time of removing the medulla from the cadaver ( p. m., March 4, 1902), an oblongata emulsion had been injected into eight rabbits. This species of animal was used owing to

a “Sur certains caraterès des lésions histologiques de la rage," by V. Babes (Annales de l'Institute Pasteur, v. 6, No. 4, Apr., 1892, pp. 209–223).

"Rapid diagnosis of rabies by the examination of the bulb of the biting dog," by V. Babes, Vet. Jour., v. 51, No. 303, Sept., 1900, pp. 158-160.