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occurrence of irregular areas of hæmorrhagic extravasation, pathological changes in the intestines, and the presence of a micro-organism in the blood and tissues of the body.
My results are more or less in accordance with those of BITTER, who regards plague as a septicemia hæmorrhagica. According to ALBRECHT and GHAR, this is only so in severe cases.
It is said that the occurrence of buboes in definite situations in the body, is strong evidence in favour of the infection having been occasioned through the some focus in the area of tissue drained by the lymphatic glands which are the seat of the bubonic enlargement. Viewing the subject from certain points of view, e.g., the study of the anatomical connections, the question of bare feet, the results of direct inoculation in man and animals, etc., there would appear to be much evidence in favour of such an occurrence.
What we have to consider is the following:-
Does the plague virus reach man in nature, through the skin? Is this the natural mode of transmission of the disease from man to man? What avenues in natural infection do we find in animals? Are the modes of infection the same of man and animals? Is there evidence of the channels of infection in man?
The consideration of the points in the presence of a large amount of plague material, has led me to conclude that the opinions arrived at by many investigations are, on better acquaintance, by no means obvious.
In the first place, many cases of plague are not definitely bubonic. The lymphatic glands are enlarged but no series forms a definite bubonic formation. We may have epidemics of plague in which so salled septicæmic plague is most prevalent.
Again in epidemics, the bubonic type may be most prevalent.
Different epidemics show great variations in the type of the disease present. A certain annual variation is found. So called septicemic plague is present during the whole epidemic, but bubonic plague may only be in evidence during certain times of epidemic. Other evidence in regard to these points is given in an attached table showing the relative prevalence of the so called different types of the disease throughout the years 1902-1903.
Further buboes may be double or multiple. One may be present in each groin or axilla, or one in the iliacal region, with another in the neck. In other cases of multiple bubonic plague, buboes are found in the most unexpected places. Again it is said that femoral buboes are most common amongst those who go about barefooted, e.g., the Chinese. I find, however, that buboes in this situation, or in the groin, are as common amongst Europeans who are well booted.
In cases of bubonic plague, it is only in rare instances that evidence is forth- coming as to the presence of wounds, abrasions, etc.
It is not denied for a moment, that plague infection frequently occurs through the skin and is followed by the formation of a bubo. In these cases, I am of opinion, that some evidence of such an infection is present on the skin. In animals inoculated by this method, such evidence is usually present, and in all the cases of authenticate infection through the skin which I have come across, there has been evidence of entry of the B. pestis. A papule, blister, a pustule or even a wound present in the skin, and frequently the plague bacillus has been found locally. An excellent example of such an infection has already been given under "Symp- toms of l'lague."
Such cases do occur, but I am of opinion, they are rare, and do not clarify our ideas to any great extent as to the spread of plague from man to man during epidemic times. In fact I would urge that the importance attached to skin infer- tion in plague has been exaggerated.
Again, granting such a skin infection, there is no evidence to show that the B. pestis is shut up in these bubonic enlargements. I believe that general blood infection takes place soon alter the introduction of the virus and usually long before the appearance of the bubo. (Vide Symptoms of Plague.)
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