In cases that recover the fever diminishes, exacerbations cease, ulcers granulate and cicatrize, vesicles dry up, the nodules and enlarged glands diminish, the erysipelatoid swellings of skin and nose subside, and a very tardy and imperfect convalescence is established.
The duration of chronic glanders, nasal or cutaneous (farcy), is exceedingly indefinite, varying from three months to ten or eleven years. One of the most protracted cases is that recorded by Bollinger of a veterinarian who, after an eleven years' illness, recovered with cicatricial contraction of the nose and larynx and a decided cachectic appearance.
MORBID ANATOMY.—Besides the lesions above mentioned as occurring in the skin and mucous membranes of the nose, mouth, and pharynx, the frontal sinuses, the larynx, and less frequently the lungs, are the seats of the specific glanderous processes. In the lungs there are then the nodules, hard, caseous, or purulent according to their age, and varying in size from a millet-seed and pea upward to the involving of the greater part of a lobe. Beneath the pleuræ may be seen ecchymoses, hard, fibrous nodules, and yellow elevations, which on being incised furnish grumous pus. The spleen is usually enlarged, gorged with blood, gray or black, and is the seat of suppuration. The liver is enlarged, softened, and may be the seat of glanderous processes, with ulcers in the bile-duct or gall-bladder. The joints, like other serous cavities, become the seat of specific suppuration. The bones are often implicated in adjacent deposits, especially in the face, cranium, and hands, so that the compact tissue may become reduced to the merest shell, while the medulla and periosteum abound in the specific products. The cerebral meninges and brain-tissue are frequently the seat of specific growths and minute abscesses. It is noticeable that the enlargement of the lymphatic glands is usually less than it is in the horse, though they are never entirely free from lesions. Indeed, the tendency in man to the formation of considerable glanderous neoplasms is much less than in the solipede.
The microscopy of the lesions is essentially the same as in the horse. O. Wyss describes the cutaneous nodules as formed by a great proliferation of round cells (like pus-cells) in the upper layer of the corium just beneath the papillary layer. In a more advanced stage the corium and papillæ are filled with pus-cells, and, becoming disorganized, give rise to the formation of pustules and small abscesses. Lagrange describes in a chronic ulcer of the palm, a layer about 2 mm. in thickness of embryonic cells closely packed with an amorphous intercellular substance. The nuclei appeared larger than in ordinary ulcers or tubercles. Extending into this layer were capillary vessels packed with red globules and with blind extremities, or in some instances minute ruptures and hemorrhages. Beneath this superficial cellular layer was a stratum of striated muscle, especially noticeable for the excess of condensed connective tissue making up the intermuscular septa, and the great multiplication of nuclei with large, clearly-defined nucleoli, not only inside the sarcolemma, but also between the fibrillæ and separating them widely. At some points the muscular tissue had undergone a vitreous degeneration, while at others were many fusiform cells. At one point, where the ulcer extended to the phalanx, the compact layer of the bone was attenuated to the thinnest shell and perforated, so that the medulla was continuous with the ulcer. The medulla contained a great number of white globules, medulla-cells, and minute embryonic nuclei. The vessels were remarkable by the extensive fibroid thickening of their coats. On section of the ulcer many orifices stood widely open because of the rigidity of their walls. The internal coat was plicated, as if too large for the lumen. The external fibrous layers were at points abundantly interspersed with, and even replaced by, groups of embryonic cells, the active proliferation of which meant the destruction of the perivascular fibrous layer. These embryonic cells even invaded the lumen of the vessel and partly blocked it, so that the remnant of the tube remained as the centre of a disintegrating mass, or later a caseous or purulent focus.
DIAGNOSIS.—Acute glanders, when well developed, is unmistakable. The presence on or near the skin of the characteristic nodules, pustules, phlyctenæ, and ulcers, the oedema or erysipelatoid condition of the adjacent skin, the redness of the lymphatics, the presence of the neoplasms and ulcers in the nose, and the sticky, fetid, variously colored nasal discharge, with the acute fever, prostration, and pains in the limbs and joints, make a tout ensemble that is pathognomonic. In the initial stage only it may be confounded with rheumatism, but the arthritic pains are not usually attended by the same amount of redness and swelling of the joints, the prostration is far more profound, and there are in most cases an irritable, unhealthy-looking wound and a history of exposure to infection from glandered horses.
In chronic glanders, and especially in the external form (farcy), the diagnosis is often more difficult. From pyæmia and septicæmia it is usually to be distinguished by the comparative absence or the slightness of the chills, by the less healthy character of the pus, and by the implication of the nasal mucosa, the larynx, and lungs. When the nose, larynx, or lungs are but slightly affected, there may be a strong resemblance to syphilis or miliary tuberculosis, but a close attention to the character of the lesions, the absence of any concomitant history or symptoms of syphilis, and deductions drawn from the occupation of the patient and the presumptive exposure, will greatly assist in reaching a diagnosis.
The detection of the bacillus is not conclusive, as in tuberculosis and some forms of septicæmia there are similar organisms, agreeing with the microbe of glanders even in the matter of size. In cases of doubt a little delay will usually allow the development of new and more characteristic symptoms.
The final resort, however, is to inoculation. Auto-inoculation, as practised by Poland, is rarely satisfactory, as the system has acquired a partial tolerance of the disease and local lesions are not so certainly developed as in the healthy subject (St. Cyr). Inoculation on a healthy goat, sheep, or rabbit can always be availed of, and if practised on more than one subject can be relied upon, as the virus loses nothing of its power in passing through the human system, but usually determines an acute form of the disease in the animal inoculated.
PROGNOSIS.—Acute glanders is almost constantly fatal to man. Of chronic cases, and especially the external form (farcy), from one-third to one-half of the subjects recover. When both internal and external (farcy—glanders), the issue is usually fatal. Kütner claims that cases caused by external inoculation are more favorable than those caused by the inhaled poison. This accords with the general principle, that a poison viable in the comparatively vitiated air of the lungs or on the surface of the intestinal canal is better fitted by its habit of life for survival in the blood and plasma, and is consequently more redoubtable. The greater the duration of the disease in any particular case, the more favorable is the prognosis.
TREATMENT.—In the treatment of glanders in man the same principles must guide as in animals. In external, inoculated cases the wounded tissues should be early destroyed by potent caustics—fuming nitric acid, corrosive sublimate, iodized phenol, chlorine, sulphate of copper, carbolic acid, or the hot iron. The erysipelatoid swellings may be treated by leeching, followed by solutions of carbolic acid, iodine, or chlorine-water, by ice, and internally by laxatives and iodide of potassium. The first two antiseptics may be freely used by hypodermic injection. Abscesses and tumors should be laid open and cauterized as above, and then treated by weaker solutions of the same agents. Nasal ulcers may be treated by insufflation of iodoform and injections of creasote, carbolic acid, nitrate of silver, or permanganate of potash solutions. Of the greatest importance is a general tonic and stimulating regimen. A nutritious diet (including beef-tea), abundance of pure air, alcoholic stimulants, quinia, tincture of the chloride of iron, and, above all, arseniate of strychnia, have been used with advantage. Various anti-ferments, such as the bisulphites in full doses, carbolic acid, and iodide of potassium, have apparently proved beneficial, and deserve a further trial. As in the horse, a great variety of other agents, mostly of a tonic nature, have been employed, but with very variable results.