24 



well understood. So the statement that all changes, except those 

 of the lymph glands and the tissues of their immediate neighbor- 

 hood, are generally insignificant, is untenable. We have among our 

 own cases, some of pneumonic and septicsemic plague, in which the 

 changes in the glands are quite insignificant compared with those 

 in other organs, and of course this observation is at present not 

 at all new. 



It is very interesting to note that in Yamagiwa's third case, where the 

 hemorrhagic edema and the swelling of the cervical and submental glands 

 was enormous, and the consequent pressure upon the trachea very great, the 

 latter suffered an incomplete fracture of its cartilages and became flattened 

 out into a scabbard-like canal. The frequency and importance of sub- 

 mucous and subserous hemorrhages in plague were duly emphasized by 

 Yamagiwa, and he calls attention to the fact that in the affected lymphatic 

 chain the gland nearest to the point of entrance of the bacillus is more 

 profoundly changed than are those farther away. However, this is not 

 always the case. Other changes particularly mentioned are parenchymatous 

 nephritis and cloudy swelling of the liver and heart muscle, acute swelling 

 of the spleen, and edema of the lungs. The main histologic alterations 

 described are degeneration of the renal epithelium with granular material 

 in the tubules, cloudy swelling of the liver parenchyma cells, dilatation of 

 splenic vessels with hemorrhagic infiltration, necrotic foci and the presence 

 of plague bacilli, dilatation of pulmonary vessels with interalveolar blood 

 extravasation, vascular dilatation, phlebitis and necrosis of the lymph 

 glands and of the periglandular tissue. The extensive blood extravasation 

 in the affected glands is explained in the following words: "The profoimd 

 change in the walls of the veins, the great loosening (Auflockerung) of the 

 substance of the vessel walls in consequence of cellular infiltration, brings 

 about colossal blood extravasation inside and outside of the lymph glands." 



The credit of having first lucidly and correctly described a form 

 of plague which is now universally recognized as a separate and 

 important type — plague pneumonia — belongs to Childe of the 

 Indian Medical Service. Since his description of the pathology 

 of plague pneumonia has not been given the prominence it well 

 deserves, by several writers, it will here be quoted somewhat at 

 length. Of course reference to a pneumonic form of plague had 

 been made long before Childe's publication. 



In fact, it had been well observed during the Middle Ages. During the 

 great plague pandemic which decimated Europe between the years 1347-1350 

 pneumonic plague was very prevalent and Guy de Chauliac, the physician 

 of Pope Clement VI, who observed the plague in Avignon, and who himself 

 became very sick with it, distinguished two types and wrote: "Pestis 

 habuit duos modos. Primuis fuit per duos menses cum febre continui 

 et sputo sanguinis. Et isti moriebantur infra tres dies. Segundus fuit 



