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.
PROPHYLAXIS AND TREATMENT OF GLANDERS.
Extinction. Exclusion, in Australia, New Zealand, English army. Occision of infected, and disinfection of stables, harness, vehicles, utensils, manure and other infected things, mallein diagnosis; attendants should avoid handling suspicious horses, except with sound hands, and disinfect latter. Sheep living in horse stables, tested before slaughter, or inspected after. Malleinization on Plains and in high, dry air, in secluded herds: less hopeful elsewhere. Mallein test for all solipeds from glanders districts, and imported horses. Treatment illegal in many states, so that justice would require extinction with indemnities. Successful on high tablelands and mountains. Demands careful segregation and disinfection. Acute cases always hopeless: chronic skin cases more promising. Antiseptic injection of unbroken nodules (carbolic acid, potassium permanganate), also of open sores (mercuric chloride, iodized phenol, cupric sulphate, saturated, zinc chloride), excise nodule. For delicate mucous surfaces Lugol’s solution of iodine or iodized phenol diluted. Tonics: arseniate of strychnia, copper biniodide, baryta nitrate, iron sulphate, sulphites, bisulphites, hyposulphites, phenic acid, open air life at pasture, or thorough ventilation, sunshine, moderate exercise, generous, partly grain diet. Mild cases in separate herd, in secluded, wide pasture with rich diet, including grain, and shelter in clean, comfortable shed at will, under tonics and antiseptics, tested by mallein at intervals, to be restored individually to work after two or more tests without reaction. Serum of immune animals subcutem. Treatment in man: surgically as in the horse, excision, curetting, antisepsis, abscesses opened and disinfected; iodoform insufflations, antiseptic gases, sprays and solutions. Internally: tonics, sulphocarbolates, iron muriate, iodides, phenic acid, quinia, strychnia, arsenite, stimulants, serum treatment, pure air, out door life, rich, digestible food.