376
Looked at in this light it is not difficult to understand the production of a septicemia early in the disease as a result of infection through the skin and via the lymphatic system.
Once septicemia is established the post mortem appearances characterising most plague cases follow as a matter of course.
of
The prevalence of enlarged (congested) and haemorrhagic glands generally throughout the body is as natural a sequence of a septicemia as is the presence petechial hemorrhages in the peritoneum or the general degeneration of the cells. throughout the body.
In the Report on Plague by the Government Bacteriologist of Hongkong we find the following remarks: "Again the bubo is usually developed in and "around the lymphatic glands which are not in direct connection with the area of "skin through which the infection is supposed to have occurred. The deep and not "the superficial lymphatic glands are usually affected, and in groin buboes, the "glands situated inside the abdomen, namely, the iliac lymphatic glands, are the most severely affected and form the central core of the bubonic formation. The "changes
** are usually much more pronounced inside the boundary of "Poupart's ligament, than inore distal, namely in the inguinal and femoral groups "of lymphatic glands."
CL
*
These remarks follow a statement to the effect that it is almost impossible to find any evidence of a point of innoculation through the skin.
If then no point of innoculation can be decided on, how has it been decided that the glands not in direct communication with lymphatics from this point are more often infected than those which are in direct communication? My suggestion above relative to the possible passage of the bacilli through the glands in the early progress of the disease seen to me to have some application here.
But there is another most important point to be considered, namely, the course of lymph through these glands and their mutual relations.
It must be remembered that amongst other areas drained by the superficial inguinal glands is the integument of the perineum and genital organs and that either directly or via the deep inguinal glands the efferent vessels from these are in communication with the external iliac glands.
The internal iliac glands receive the lymphatics from the pelvie viscera and parietes. Remembering that an infection through the genital organs is not by any means an improbability the development of buboes in the above mentioned internal iliac glands is not to my mind evidence in favour of primary intestinal infection as the chief path.
In his Research into Epidemic and Epizootic Plague 1904, page 39, the Government Bacteriologist mentions the Austrian Plague Commissioners' obser- vation that plague could be induced by rubbing the bacilli into the shaved skin of a rat or guinea pig and goes on to question the supposition that a so shaven skin can be considered as having an unbroken surface and to call to mind the likelihood of there being microscopic wounds produced by a process of shaving which afford entry to the bacilli.
If it be admitted that such microscopic wounds might be the point of entrance, it appears to me to be equally admissible to support the suggestions of the Indian Plague Commission that the bacilli may gain entry through very slight lesions of the skin such as I have mentioned above.
The frequency of groin buboes in people who wear boots, such as Europeans, when considered in connection with the total areas of skin drained through the superficial inguinal glands is not very strong evidence against infection through the skin. It is not, the lower limb alone which is drained through these glands.
I cannot accept as evidence against the skin-infection theory that those who are employed in the work of disinfection, removal of cases and infected rats, are not more often attacked by plague in its bubonic form.
*
Op. cit., page 13.