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(c.) The occurrence of lymphangitis.

(.) The demonstration of plague bacilli in the vesicle, and in the blood

24 hours later.

(e.) The late appearance of the bubo,

(f.) The occurrence of secondary vesicles, containing plague bacilli.

(g.) Noteworthy is the presence of initial symptoms pointing to an

affection of the gastro-intestinal tract.

This case is a good instance of bubonic plague with undoubted blood infec- tion. The formation of the bubo was certainly a secondary process if we consider the exact date of the onset of the illness. The bubo did not develop for several days, during which, there was headache, diarrhea, vomiting. somnolence and plague bacilli in the primary vesicle and in the blood. Many similar instances of this were found during the epidemic of 1903. The patients came to Hospital complaining of headache, vomiting, and diarrhoea. The blood was examined for malarial parasites by the thick blood film method, but instead of these parasites, appreciable numbers of plague bacilli were found. At this time the buboes had not developed. The cases were transferred to Kennedy Town Hospital where typical bubonic manifestations showed themselves in a very short time.

Another evidence of severe blood infection in this case of bubonic plague, was the occurrence of crops of vesicles in other parts of the body, these containing plague bacilli.

The occurrence of papules, vesicles, etc. on the skin in cases of plague is of great interest from the point of view of blood infection. In the majority of cases the B. pestis can be isolated from such eruptions. Sometimes the plague bacillus is present in pure culture, but this is rare except during the initial stages of such eruptions. In the vesicular stage, the B. pestis is often mixed with staphylococci, or streptococci, and in the pustular stage, ordinary pyogenic bacteria form the majority of micro-organisms present in the pyoid discharge. The larger pustular eruptions remember one of boils or even carbuncles, but a slight acquaintance with their anatomy shows one that they are of an entirely different pathology.

Eruptions in plague vary in degree. Occasionally they are absent. Again several papules or vesicles may be present in different parts of the body. In one or two cases which have come to my notice, the vesicular eruption over the skin was most pronounced. Papules and vesicles with occasional small pustules were thickly scattered over the body. In fact in one of the cases, the eruption and especially the vesicular eruption was so pronounced, that the body looked as if small-pox was present. An examination of the vesicles, however, showed the presence of plague bacilli. 1 find that GOTSCHLICH and ZABOLTONY have found similar cases in which varicelloid like vesicles and pustules were scattered over the whole body, and bacilli could be demonstrated in their serous content.

The

The question of the occurrence of lymphangitis is a matter of considerable dispute. Its non-occurrence in cases of bubonic plague is believed to be charac- teristic by many investigators, and special note is made of this fact by the mem- bers of the several Plague Commissions, especially by ALBRECHT and GHON. general opinion is that the B. pestis affects an entrance through the skin and travels to certain lymphatic glands by way of the lymphatic vessels. In and around these glands a bubo is developed. In no case, however, is there anything like a lymphangitis, between the point of infection and the site of the bubo.

That such a mode of infection through the skin is the common one and one which obtains in nature is by no means obvious. It is usually, in fact almost always impossible to find any evidence whatever of a point of inoculation through the skin. 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 lympha- tic glands are usually affected, and in groin buboes, the glands situated inside the abdomen, namely, the ac lymphatic glands, are the most severely affected and form the central core of the bubonic formation. The changes such as hæmorrhagic extravasation into the connective tissue around the glands, and the swelling, oedema, and degeneration of the glands themselves are usually much more pronounced inside the boundary of Poupart's ligament, than more distal, namely, in the inguinal and femoral groups of lymphatic glands.