Text book of veterinary medicine, Volume 4 (of 5)

by James Law

GLANDERS IN MAN.

Recognized by Lorin 1812. Causes: infection from soliped, man less susceptible; infection from man, clothing, stable bucket, inhalation, etc.; industrial disease; native immunity. Symptoms: incubation; mistaken for carbuncle, small pox, measles, erysipelas, anthrax; anamnesis; anthrax focus has darker center, no caseation, no corded lymphatics; nodules and ulcers in nose, swollen submaxillary glands and lymph vessels, general illness, diarrhœa, vomiting, dyspnœa, mental derangement, stupor, coma, internal deposits, bloody sputa, fœtid breath, hepatic pain, icterus, muscles, bones, bowels, typhoid, pyæmic, osteo-myelitic, or acute tuberculous symptoms. Death in 3 days to 4 weeks. Chronic cases, cutaneous, muscular, osseous, skin nodules in group or chain, glandular swellings. Diagnosis from pyæmia by lack of chills, and the sanious pus; from syphilis by futility of potassium iodide, and history; inoculate ox or white mouse; find bacillus. Lesions: as in horse, more early coagulation necrosis, ulceration, abscess; pus more viscid than in pyæmia, walls of abscess more irregular, lymphoid cell proliferation more abundant and extended (glands, spleen, liver, lung, nose, etc.), history; distinguished from variola, rötheln, and erysipelas by the many miliary or pea-like neoplasms with cellular caseating centres; lymphoid deposits in bone marrow, with friability.

Until the early part of the present century glanders in man was not traced to its origin in the soliped. Lorin in 1812 recorded a case in which the human hand had been accidentally inoculated from handling a horse suffering from farcy. Soon other cases were put on record by Waldinger and Weith, Muscroft, Schilling, Rust, Sedow, and a host of followers. Later Rayer, Tardieu, Virchow, Leisering, Gerlach and Koránye have thrown much light on the subject.

Etiology. Man is manifestly less susceptible than the soliped, considering the great number of exposures relatively to the victims. Yet the infection of man is altogether too common to be lightly passed over. The infection is almost always derived directly or indirectly from the horse, yet a number of cases have been derived from the human being through handling the dishes, towels or handkerchiefs of a patient, dressing his wounds, or performing a necropsy. Other cases like that of Dr. Hoffmann of Vienna, came from handling artificial cultures of the bacillus mallei.

Glanders is preëminently an industrial disease, attacking persons of the following occupations: hostlers 42, farmers and horse owners 19, horse butchers 13, coachmen and drivers 11, veterinarians and veterinary students 10, soldiers 5, surgeons 4, gardeners 3, horse dealers 2, policeman, shepherd, blacksmith, employe at a veterinary school, and washerwoman, 1 each.

The modes of transmission are essentially the same as in the animal. In the great majority of cases there has been the direct contact of the infecting discharges with a wound of the human victim. Handling the diseased horse with injured hands, giving him a bolus and scratching the hand on the teeth, examining the nose, sleeping under a blanket which has been used on a glandered horse, removing the dressings of such an animal or performing a post mortem examination on him are familiar examples. The particles scattered by the diseased animal in snorting, will infect the mucous membrane of the eye or nose, and all the more readily if these are already sore or abraded. Infection of man by ingestion has been discredited mainly because the carcasses of glandered horses have often been eaten with impunity; but this may be largely accounted for by cooking, the bacillus being destroyed by a temperature of 131° F. Carnivora such as dogs, cats, lions, polar bears and prairie dogs have been infected by feeding. Men also have been infected through drinking from the same bucket after a glandered horse. After making full allowance for the inimical action of the gastric juice, we must admit that this has often failed, and there is the added danger of abrasions of the lips, mouth and throat and of the entrance of the microbe into the tonsillar follicles and gland ducts. Still other cases are recorded of men sleeping in stables, but not handling horses, who contracted glanders, presumably, through the dust borne bacillus inhaled. The bacillus, is however, so readily destroyed by thorough desiccation that this mode of transmission is exceptional. Some men are immune to glanders, and suffer only when predisposed through a course of ill health, and yet a large proportion of the cases on record have been in strong hearty men.

Symptoms of Glanders in Man. In man as in the horse, glanders occurs in the acute and chronic forms. In the acute supervening on an external inoculation, incubation is from one to four days. When it enters through other channels it may seem to extend to a week or more.

When a skin abrasion has been inoculated it will show in a few days a soft inflammatory swelling or a firm nodule with a puffy reddish areola, and it may be mistaken for a carbuncle. In not a few cases the small nodule has been mistaken for small pox. In my experience a horsemen on a ranch on which over a hundred horses showed glanders, died of an ulcerous skin affection which was variously supposed to be a malignant small pox and measles, though neither malady was known to exist in the district. Other cases are confounded with gangrenous erysipelas. The absence of these other affections from the locality, and the fact that the patient was employed about glandered horses, should go far to correct such mistakes. The early supervention of ulceration is further diagnostic, and discovery of the bacillus mallei in the products will be conclusive. From anthrax it is easily distinguished by the absence of the dark centre of the sore in the early stages, and of the large sized bacillus anthracis. The caseation or liquefaction of the necrotic centre further distinguishes it from the characteristic anthrax slough, and the thickening and induration of the lymphatic walls are not present in anthrax. Sometimes the inoculated case proves mild and recovers in two or three weeks with healing of the ulcer, but in other cases there is an extension to adjacent tissue and a general infection with the supervention of nasal glanders.

There is a spread of the erysipelatoid inflammation and swelling, and the formation in such newly invaded tissue of nodules and ulcers in successive crops. In acute cases too, the nasal mucosa becomes involved with the formation of the nodules and ulcers that are so pathognomonic in the horse. The discharge is then somewhat sticky and often tinged with blood. In acute cases according to Senn, the nose may be completely destroyed and deep facial ulcers may be formed in a week. The submaxillary glands are enlarged and painful and the facial lymphatic vessels leading from these to the nose may be red, thickened and tender. Suppuration and ulceration of the glands may ensue. Headache, prostration, nausea, inappetence and vomiting with diarrhœa usually supervene. Then follow dyspnœa, wakefulness, troubled dreams, anxiety, nocturnal delirium, stupor and coma. The pulse may rise to 120 and the temperature to 104° F.

There may be various complications as deposits in the lungs with pain in the chest, weak cough, aphonia, bloody expectoration and offensive breath; or the morbid process may take place in the liver or spleen with pain in the hypochondrium and much prostration and even icterus; or the muscles, bones, joints or testicle may suffer and the symptoms may suggest typhoid fever, pyæmia, osteomyelitis, or acute general miliary tuberculosis. The bacillus can usually be detected in the blood.

Acute glanders may prove fatal in three days or it may be prolonged for two, three or even four weeks.

Chronic glanders in man usually confines itself to the cutaneous muscular and osseous systems. It may take on an indolent type with the formation of skin nodules in groups or chains which remain hard and show no tendency to soften nor ulcerate. The adjacent lymphatic glands may become enlarged and indurated and the affection strongly resembles tuberculosis of the skin. Later when the nodules have softened and formed irregular and obstinate ulcers with swollen lymphatic glands, the disease is easily mistaken for syphilis. From pyæmia and septicæmia it is usually to be distinguished by the comparative absence of chills, and by the more sanious character of the pus. From syphilis it may be distinguished by the futility of a course of potassium iodide, and the general history of the case and probable exposure of the patient, and for tuberculosis the same principles will apply. In case of uncertainty, inoculation may be resorted to on the horse in suspected syphilis and on the pig when there is suspicion of tuberculosis. Or conversely the ox may be employed for the latter disease as he is altogether insusceptible to glanders. As a last resort the discovery of the bacillus may be made or the mallein test may be adopted with the concurrence of the patient.

Pathological Anatomy and Diagnosis. This is fundamentally the same as in the horse. The bacillus and its toxic products act on the infected tissues to produce clusters of lymphoid cells in a fibrous stroma after the manner of tuberculosis. Like that disease it also tends to affect primarily the lymph channels and glands, showing a particular tendency to the respiratory mucosa and has a great disposition to early coagulation, necrosis, ulceration, suppuration and abscess. The giant cell of tuberculosis is not a prominent feature in glanders, and the disposition to suppuration is greater especially in the human being so that the disease often resembles pyæmia. As in solipeds, however, the glander abscess has somewhat more sanious or glairy contents and the investing wall is not smooth and regular, but uneven and ulcerous from the successive softening and discharge of the clusters of degenerating lymphoid cells in the adjacent tissue. The pallor of the adjacent tissues from exudation and from the presence of numerous nests of lymphoid cells, the thickening of the efferent lymphatics, and the presence of numerous lymphoid neoplasms in the adjacent glands, and tissues, and often in the internal organs such as the liver and spleen and in the nasal mucosa or lungs together with the history of the patient’s exposure to glanders serve to diagnose from pyæmia. From smallpox and rötheln the skin lesions are distinguished by the presence of a central coagulation necrosis bathed in a glairy seropurulent fluid, and by the infiltration and thickening of the efferent lymphatic trunks. It differs from erysipelas in the same way by the presence in the affected tissues of the small hard lymphoid masses of embryonal tissue, and in a more advanced stage by the granular fatty debris resulting from their fatty degeneration. The presence in the affected tissue of these miliary or pea-like neoplasms in all stages of development from the primary congestion, through the embryonal tissue to the coagulation necrosis and caseation or softening is characteristic of the lesions of glanders. The sanious, sticky or glairy pus is especially noticed in the newly opened abscess, as after exposure to the air it is speedily infected with pus microbes, and the discharge becomes less serous and more creamy. Another characteristic of glanders in man is the frequent implication of the bone marrow, and the formation of the lymphoid deposits in the cancellated tissue until the bone may be reduced to a mere friable shell. Even when the disease is localized in the nasal mucosa it extends rapidly, not only to the skin and muscles, but also to the cartilage and bones of the face, so that deep, wide, perforating and destructive ulcers are common. The enlarged ends of the long bones of the limbs are favorite seats of the lesion, and the synovial membrane of the joints and the articular cartilage often bear centres of lymphoid proliferation. Though usually small the intermuscular neoplasms may form abscesses as large as a hen’s egg. The affected muscle appears pale, degenerated and granular with foci of lymphoid cell growth. The swelling of the lymph glands is usually less than in the soliped though the same in character. The pulmonary neoplasms are histologically almost indistinguishable from tubercle, though the comparative absence of the giant cell, the different staining qualities of the bacillus, and the coincident lesions in the upper air passages, with the cord like infiltration of the walls of the lymphatics may assist in diagnosis. Diagnostic inoculation may be made on the basis of the susceptibility of the ox and white mouse to tuberculosis, and their insusceptibility to glanders; also the partial insusceptibility of the soliped to tuberculosis and his marked susceptibility to glanders.

The characteristic nodules and abscesses may be found in different internal organs such as the stomach, intestine, liver, spleen, kidneys, testicles and brain, especially in acute cases, whereas the lesions of the skin and nose are more common in chronic cases.