44° PLAGUE. 



lection of enlarged glands fused by the inflammatory swelling. 

 True suppuration is rare. Usually one group of glands is 

 affected first, constituting the primary bubo — in the great 

 majority the inguinal or the axillary glands — and afterwards 

 other groups may become involved, though to a much less 

 extent. Along with these changes there is great swelling of 

 the spleen, and often intense cloudy swelling of the cells of the 

 kidneys, liver, and other organs. There may also occur second- 

 ary areas of haemorrhage and the necrosis, chiefly in the lungs, 

 liver, and spleen. The bacilli occur in enormous numbers in 

 the swollen glands, being often so numerous that a film prepa- 

 ration made from a scraping almost resembles a pure culture 

 (Fig. 147). In sections of the glands in the earlier stages the 

 bacilli are found to form dense masses in the lymph paths and 

 sinuses (Fig. 151), often forming an injection of them ; they may 

 also be seen growing as a fine reticulum between the cells of 

 the lymphoid tissue. At a later period, when disorganisation 

 of the gland has occurred, they become irregularly mixed with 

 the cellular elements. Later still they gradually disappear, and 

 when necrosis is well advanced it may be impossible to find any 

 — a point of importance in connection with diagnosis. In the 

 spleen they may be very numerous or they may be scanty, 

 according to the amount of blood infection which has occurred ; 

 in the secondary lesions mentioned they are often abundant. 

 In \hz pulmonary form the lesion is the well-recognised "plague 

 pneumonia." This is of broncho-pneumonic type, though large 

 areas may be formed by confluence of the consolidated patches, 

 and the inflammatory process is attended usually by much 

 haemorrhage ; the bronchial glands show inflammatory swelling. 

 Clinically there is usually a fairly abundant frothy sputum often 

 tinted with blood, and in it the bacilli may be found in large 

 nu'mbers. Sometimes, however, cough and expectoration may 

 be absent. The disease in this form is said to be invariably 

 fatal. In the septicmmic form proper there is no primary bubo 

 discoverable, though there is almost always general enlargement 

 of lymphatic glands ; here also the disease is of specially grave 

 character. A bubonic case may, however, terminate with sep- 

 ticaemia ; in fact all intermediate forms occur. An intestinal 

 form with extensive affection of the mesenteric glands has been 

 described, but it is exceedingly rare — so much so that many 



