Fig. 68.—Axillary Bubo. (Reproduced from Simpson’s Treatise on Plague, 1905.) From Jackson’s Tropical Medicine.
There is never the rusty, tenacious sputum of lobar pneumonia. Herpes never appears, according to Childe. Heart failure is a very prominent feature of plague pneumonia.
It is fortunate that this watery sputum teems with bacilli early in the disease as smears from such sputum give an early and sure diagnosis of this terribly contagious and fatal malady. The knowledge that this infection is transmitted from man to man by the droplets of sputum expelled in coughing demands the protection by some form of mask of anyone coming near such a patient. Some observers noted splenic enlargement and tenderness over the superficial lymphatic glands. Strong has noted that the course of the disease rarely extends beyond the fourth day and that death is the invariable termination.
In 1919 thirteen cases of plague pneumonia occurred in California starting from an at first unrecognized case of bubonic plague of squirrel origin. These pneumonias were diagnosed as influenza pneumonias but later the true diagnosis was determined. McCoy notes in this connection that there is a strong tendency to pulmonary localization of plague in the squirrel which is not true of the rat.
Septicaemic Plague.—As regards the clinical manifestations of septicaemic plague, if such be considered as a separate type, Choksy states that there is no clinical sign by which such a septicaemia can be recognized without the help of the laboratory, although the presence of a thready or imperceptible pulse, in one showing the characteristic toxaemia of plague, should cause suspicion.
The patient may be so overwhelmed from the start that there may be only a slight rise of temperature. Occasionally, plague bacilli may be recognized in blood smears, a finding that practically never obtains in any other bacterial disease. At the same time blood cultures are solely to be depended upon in diagnosis and even such examinations may be negative. Liston has noted that plague patients always die if more than 40 bacilli per cc. are present in the blood. In a recent outbreak of septicaemic plague in Ceylon the only clinical manifestations were intense headache, and fever. The patients died within forty-eight hours. Until properly diagnosed bacteriologically the disease was thought to be pernicious malaria.
The Symptoms in Detail
General Appearance.—The face is at first drawn and pallid, the eyes injected and the expression one of fear or anxiety. As the temperature rises the pallor is succeeded by a flushed and dry hot skin. Later on in the disease the expression is more one of apathy. The staggering gait and the tendency to wander give the impression of alcoholic intoxication.
Temperature Curve.—The fever course of plague is very irregular. The temperature usually rises rapidly to 103° to 104°F., but tends to exhibit marked remissions by the third day. After a fall, it may rise to a very high degree just before death. Cases which recover often show a fall by lysis.