Plague / Its Cause and the Manner of its Extension, Its Menace, Its Control and Suppression, Its Diagnosis and Treatment

by Thomas Wright Jackson

Non-biologic Diagnosis.—I do not contend that other diagnostic means than biologic ones should not be used in plague.

On the contrary, it will inevitably happen at times that resort must be had to methods of diagnosis which are purely clinical. When this is the case, treatment, along lines to be detailed presently, should be instituted upon the establishment of a presumptive diagnosis. This presumptive diagnosis may be reached after due consideration of physical signs and symptoms. A carefully taken history of the onset and course of the disease will be valuable but unfortunately such histories can rarely be secured. It is far safer to mistakenly pronounce a case "plague" and to institute appropriate treatment, than it is to hesitate in the absence of a perfect clinical picture and to permit the golden moment for treatment to pass.

It must be remembered that septicæmic, bubonic and pneumonic plague are all manifestations of systemic infection with B. pestis; that they are all expressions of the same disease; that they call for the same treatment and that when the distinctive signs of bubo or pneumonia appear the disease is dangerously advanced.

It should also be realized that every case is, almost from its onset, a septicæmic case, either mildly or overwhelmingly so. Accordingly the treatment should invariably be the treatment of septicæmic plague.

The attitude of the diagnostician should be one of suspicion and he should have the courage to carry out antiplague treatment, practically upon suspicion. In this way only can the mortality of plague be greatly reduced. It is true of plague, just as it is true of cholera, that many of the fatal cases develop and become hopeless before the disease is suspected or diagnosticated. It is also true that many fatal cases of plague, in times of epidemic, completely escape recognition during life, the diagnosis being made in the autopsy room.

Therefore, I lay great stress upon the necessity for an attitude of suspicion on the part of practitioners, wherever even a single case of plague (human or rodent) is known to have occurred.

When it becomes necessary to establish a presumptive diagnosis, i.e., without resort to the microscope, the following symptoms and physical signs will be found to be most significant.

Symptomatology.—Acuteness of onset; rapidity of fever development; rapidity of the development of mental dulness or cloudiness, impairment of speech, delirium, stupor or restlessness; early and extreme prostration (perhaps more pronounced than in any other acute disease); extreme tenderness over involved gland masses, in the bubonic type of plague; cough, with considerable frothy sputum, soon becoming blood-discolored, in the pneumonic type of plague; and early cardiac asthenia in all clinical types of plague, septicæmic, pneumonic and bubonic.

The following diseases may be confounded with plague, if symptoms alone are considered: typhus (exanthematicus), influenza pneumonia, broncho-pneumonia, severe malaria, septicæmia, acute toxic typhoid, venereal bubo, mumps and tonsillitis.

I call attention again to the fact that mild cases of plague, septicæmic and bubonic, occur at times, clinical pictures in such cases being incomplete.