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.