348 ACUTE GLANDERS IN THE HUMAN SUBJECT. 
brane, which was also strongly injected. He was ordered to 
continue the mixture without the creosote, and to take beef- 
tea and wine. 
July 20th — He was much improved. He had had some 
sleep during the night, and felt hungry. The tongue was 
beginning to clean. The ammonia was ordered to be con- 
tinued every four hours. Dr. Mackenzie resigned the case 
to my care. 
From this date he steadily improved, but remained in a 
very weak and prostrated state for some weeks, showing 
the powerful shock sustained by the nervous system. I 
decreased gradually the dose of ammonia, both in quantity 
and frequency of administration, and combined with it ci- 
trate of iron. 
About a fortnight from the period of his having recovered 
so far as to be able to go abroad, he complained to me of 
what he termed rheumatic pains in the limbs, and painful 
swellings in various parts. On examination, I found some 
swelling and tenderness of the lymphatic glands in the right 
axilla, both inguinal regions, and left popliteal space. These, 
however, gradually disappeared as he regained constitutional 
strength. 
Remarks. — A careful consideration of the foregoing case 
suggests some remarks, which may be classed under five 
interesting points, viz.': 
i. Diagnosis of glanders; 
ii. Mode of communication ; 
hi. Predisposing causes ; 
iv. Peculiarity of the symptoms ; and 
v. Treatment. 
1 . Diagnosis. — The diagnosis of this terrible malady may 
often seem difficult, as is proved by the history of the various 
cases on record. The chief landmarks for our guidance ap- 
pear to be — first , the history of the case when that can be 
procured, as showing the accession of the symptoms about 
twenty-four hours only after exposure to the influence of 
the virus; secondly , the localisation of the symptoms them- 
selves, i.e., their being limited to the salivary glands, tongue, 
and pituitary membrane ; thirdly , the peculiar symptom of a 
thick and sanious discharge from the nares; fourthly , the 
tremendous disturbance of the nervous system, so unusual 
in ordinary cases of salivation, and out of proportion to the 
local distress ; fifthly , peculiarity of the foetor ; and, sixthly , 
obstinate resistance of the disease to ordinary remedies, and 
its rapid yielding to diffusible stimulants in large doses. In 
most of the cases upon record, swelling and redness of the 
