In Utah most of the cases showed local lesions at the site of the fly-bite and subsequent swelling and suppuration of adjoining lymph glands. The local lesions were generally observed about the head or on parts of the body not covered by the clothing. There is a rather sudden onset with chilliness or rigors, generally associated with dizziness, prostration and malaise. Headache is usually present and there may be complaints of pains in the back and limbs. The temperature rises rapidly and when first taken during the rigors may reach 103° or 104°F. An irregular fever course follows for two or three weeks. There is practically no apathy, thus differentiating the mental state of typhoid fever or the marked clouding of the consciousness of plague. At times we may have rhinitis and epistaxis.
Physical examination is almost invariably negative. The spleen is not palpable. The pulse is rather rapid and the blood pressure uninfluenced.
The white and differential counts vary but little from normal.
The main feature of the disease, aside from local lesions when these are present, is prostration and this continues marked during the several weeks or months of convalescence.
It is a disabling illness rather than a dangerous one though a fatal case is recorded.
In the six laboratory infections above referred to, there were no local lesions except in the case of one man who had had previously an attack of the disease. In the second attack, two years after the first one, there was noted a papule on one finger with subsequent involvement of the epitrochlear and axillary glands. A guinea pig inoculated with blood taken from the papule became infected and showed the typical lesions of tularaemia.
There was no fever or malaise in this second attack, thus showing a degree of immunity. In cases showing conjunctival ulcerations with glandular involvement Wherry and Lamb obtained cultures of B. tularense from inoculated animals.
Diagnosis
There is very little in the clinical picture, other than the local lesions, to indicate a diagnosis.