THE CARBI^CULAR FORM OF PLAGUE.* By &AN^DRA NATH MITTBA, m.d. (Cal.),

Demonstrator in Pathology, Medical College, Calcutta.

Tm? following cases of eai'buiiouliir plague are first given, "comment on the snbject will

follow below :?

Case No /-Chilai, Hindu male, aged 33 years, . , ,

'

f f^nipntta, shoe-maker by occupation.

Admitted '

Uth March 1902. Discharged 19th Ap.il

wxo-y?-Ab0,a' blf0re,al,mrf1i?j' he observed a pimple at the site

of the carbuncle. It had

intense burning and itching sensation, and he acci-

dentally scratched it. The same eve,,,,,}. there was a

hard swelling about the a.M of a. rupee, which was very

red and hot, with a small boll at the site of the original

pimple The next morning the swe ling enlarged and

.round the boil a number of pimples appeared, the i,.tense burning sensation continued.

About the even-

ilg be felt feverish and there was some general malaise

mi <. ? nr.?Uict he started Ins work as usual, but ll.e nex

ten.lerness in his left axilla, though there he felt some tende,.new ^ ̂ ^ ̂ was no swe g

erness in the axilla increased. The fe\ er an 10

attained the diameter of about

Tr he^ndary M ?"<! -all boils. ? t,_ came to the surgical out-door

department of the Medical College Hospital and was

admitted into the

On a miss '

i|jng 0f about If diameter above the an inflammatory Central opening was observed

through which a greyish "lough could be seen. Around

-T^esSr^wS LdTit" way'?" JeHcW'sh vceiclee, some ^ ^ ^

11 ischarge p j10^. distinctly circumscribed

?irregularly oval in shape and seemed to be localised irreg y

OViW?utaneou8 tissue. It, was firm, did to the ekm and subcutan

^ ̂ ̂ ̂ >||d p>. ""The corresponding glands in tl.e axilla were slightly

enlarged

and 'the glande. His general condition wae not very bad,

* Revised from a thesis for the M, D., Calcutta

42 THE INDIAN MEDICAL GAZETTE. [Feb., 1907.

quite sensible, speech not affected. Pulse soft and rather

frequent. Admission temperature 99?F. On suspicion of an ordinary carbuncle it was excised

under chloroform. The carbuncle was taken to the

bacteriological laboratory where a smear preparation showed it to be a case of plague. Patient was at once transferred to the contagious ward. There was much

bleeding from the wound. Next two days, the patient had slight delirium at night, during the day he w?s well, the temperature rising up to 100?. From 15th March 1905 he was quite well. The glands subsided under belladonna application.

Bacteriological examination.?Smear preparations from the slough and the contents of the unbroken vesicles showed plague bacilli with the characteristic polar staining. The characteristic dewy translucent growth quite pure was obtained. On slant agar tubes inoculated from the same material after incubation at 37? for 24 hours. The culture showed plague bacilli only under the microscope. Stalactite growth was

obtained by inoculating broth with ghee from the tubes and incubating at 37? for six days. On 12th March 1902.?An agar tube was inoculated

from the blood of the patient, but it remained sterile. Case II.?Bishweshwar, Hindu male, aged 25

bullock cart driver by occupation, resident of Calcutta Admitted 2nd April 1902. Discharged 29th April 1902.

Previous history.? About four days before admission he had some pain and swelling with a central pimple on the inner side of his right leg. The pimple transformed into a small boil the next day and in the evening he got fever. There was much pain and burning in the boil and he had to pass a sleepless night. "The next day he felt some pain in tho right groin where gradually a swelling formed. Fever became high and so he came to the hospital and was admitted. Admission temperature, 104 2. The glands on the right groin enlarged and somewhat tender. The general condition was typical of plague with soft and frequent pulse, white furred tongue and thickened peculiar speech. The lesion on the skin on the inner side of tho right

leg just below the calf looked like a carbuncle,?a big bleb with dark opaque contents in the centre and smaller pustules with similar contents around the

central one. The swelling was composed of a dark induration about 1| inch in diameter and a fainter areola for J inch more?solid, not pitting on pressure, very tender and painful (2nd April 1902). Next day his condition was just the same. Next day, 4th April 1902, the carbuncle was a little

more extensive. The bleb was opened and the contents examined bacteriologically. The smear preparation from the contents of the bleb showed plague bacilli only. As in the previous case agar tubes were inoculated

from the contents of the vesicles which developed pure growths. These were tested for the characterstic stalactite growth, which developed in due time. On

suspicion of septicemia an agar tube was inoculated from the blood of the patient, but remained sterile. An ordinary surgical dressing with ichthyol was

applied. For the next four days the general condition remained

very bad ; he was unconscious and delirious at night. From 9th April 1902 he began to improve. The

slough had separated ; bubo also subsiding. Temperature came down tonormal on 10th April 1?02. On 11th April 1902 the bubo was opened as it was

soft and fluctuating. Discharged cured, 29th April 1902. Case III.?Chimni, H. F., '30, cooly, living at

Machuabazar. Admitted 3rd April 1902 Died 7th April 1902. Previous history.?She noticed a papule on the right

side of her chest about a fortnight before admission

just below the mamma. It had an intense burning and itching sensation, which she compared to ant bite. She

alleged it to the bite of an ant though she did not

notice any biting her. She did not mind it ; the papule remained there with

occasional burning and itching, and two days later a pustule appeared at the spot ; there was an inflamed red areola around and it began to be very tender. About two days after, the pustule was replaced by a scab.

Gradually minute boils made their appearance round tho central scab. The inflammatory areola steadily increased accompanied by intense burning and itching. About four days before admission she began to get fever which was not very high, and about this time she noticed a lump in her right axilla which was extreme-

ly tender. The fever increased, and she began to feel bad, and i:ot herself admitted into the First Surgeon's ward for treatment. Admission temperature 99 8?F. General condition

not very bad. Her look was rather anxious. Answered

questions sensibly. Pulse 110 per minute, soft and

compressible. Tongue furred and coated whitish. Local condition.?A big swelling on the right side of

the chest below tho mamma about 3 inches in diameter surrounded by a red areola spreading for 2 inches in all directions. The swelling was hard and indurated?did not pit on pressure. In the centre there was a dark-

looking slough surrounded by an undermined skin. All round there was a number of vesicles and pustules, some of which had given way showing small dark

sloughs. It was very painful and tender with an intense burning sensation. On pressure a thin sanguineo-puru- lent discharge exuded from the central opening and the broken vesicles.

The glands under the anterior fold of axilla were found enlarged and tender. These two seats of infection were connected neither by lymphangitis nor by inflammation of the skin. The case was taken as a case of carbuncle and was being treated with boric compressor. The

patient's condition grew worse?temperature rising 103? to 104? F. in the evening, and the central slough assumed a black appearance, so also some of the secondary vesicles. Malignant pustule was suspected, and on

5th April !902 the carbuncle was excised from the sub- jacent healthy cellular tissues ; the axillary glands were also removed. Smear preparations from the central

sloughs showed playue bacilli under the microscope, and the case was transferred to the plague ward. The carbuncle and the glands were taken to the Bacteriologi- cal Department. In the evening the patient's tem-

perature did not rise above 100 F. There was much

bleeding from the wound ; much bleeding from the wound next day also. Had a great flooding in tho

evening of 6th April 1902 ; the nurse said she had an

abortion. Died at 2-15 a.m., 7th April 1902.

Bacteriological examination ?Cultures were made from the gland as well as from the sloughs and the

unbroken pustules. The agar tubes inoculated from the

glands and the entire peripheral vesicles and pustules showed a pure culture of plague bacilli, while those from the sloughs showed a mixed growth of staphylococci and plague bacilli. The characterstic stalactite growth was further obtained by inoculating broth (with a little ghee on the surface) from the different tubes. The staphy- lococci were tested for their virulence by inoculating into guinea-pigs which did not react. Agar tube was inoculated from the blood of the

patient, but no growth followed. I may here add that one of the men employed in the

laboratory who was charged with the duty of wash- ing the plates soiled with the blood from the tumour and the glands unfortunately got axillary buboes on the fifth day and died on the eleventh day, presenting typi- cal signs of plague.

Case IV.?Rahimbux, M. M., cooly by occupation, resident of Calcutta, admitted 17th April 1902; dis-

charged, 17tli May 1902. Previous history.?Five days before admission the

patient felt a burning sensation on the lower part of

Feb., 1907.] CASES OF CARBUNCULAR PLAGUE. 43

the right side of the chest. The nest day a big boil

appeared on the part. He got. fever the same evening. Next day he noticed a similar boil on the left side of the back. There was much pain and tenderness. The

evening before his admission he noticed similar pain and tenderness in the left gluteal region, though there was no boil. The fever was high. He came to the

out-patient department where, from the experience of the two cases and from the general condition of the

patient, plague was suspected, and the case was admitted into the contagious ward.

Admission temperature, 103 F. General condition bad. Tongue furred white. Speech faltering. Gait

staggering. Pulse rather frequent and compressible. Nothing abnormal in the lungs Locally? A carbuncular swelling over the junction

of the costal cartilage and false ribs. The appearance was typical of carbuncle?a central opening with slough and several smaller openings around. The swelling was 1^ inch in diameter definitely circumscribed, hard and very dark in colour, with a definite areola of lighter tint all round which had no pustules. Another on the left side of the back about the angle

of the scapula, rather smaller but more tender. There was a number of pustules around the central opening. On the gluteal region nothing was observed. The right eye was slightly congested. No glands could be detected anywhere The diagnosis was confirmed by bacteriolo- gical examination.

18</t April 1902.?Temperature between 101 and 103 6?F. General condition as before. The carbuncle on the chest wall was very painful,

but no more pustules came out ; purulent matter and bits of slough coming out of all the openings. More pustules appeared on the carbuncle on the back ;

some had given way. A carbuncle developed on the

gluteal region where the patient was complaining of burning pain.

19th April 1902.?Temperature between 102 and 103'4?F. General condition rather worse. Carbuncles circumscribed, not increasing 5 discharging sloughs and sticky purulent fluid.

Another carbuncle appeared on the left buttock, but this was much smaller than the others. Complained of pain in the perineum where slight cutaneous inflammation was observed.

20th April 1902.?Temperature normal in themorning. Carbuncles were better. General condition improved.

Henceforth convalescence began ; temperature keeping normal with occasional rise, but. never above 100?F. The carbuncles gradually healed. Those on the buttock and the gluteal regions subsided with breaking down of the central pustules and separation of the central slouqh without any occurrence of secondary pustules. The inflammation in the perineum subsided. The conjunc- tivitis gave him some trouble. He was transferred to the convalescent ward on 10th May 1902, and discharged on 17th May 1902 as quite cured.

Bacteriological examine how* On the day of admis- sion the contents of the vesicles and the sloughs were examined as in tiie previous cases In the smear pre- paration on 1 y pi a gu e baci 11 i were found ; theagar cultures from the sloughs and the contents of the vesicles showed pure growths of plague bacilli. The stalactite test was positive on 19th April 1902. Tubes were inoculated with the blood of tlie patient, but no growth occurred.

Remarks.?This case was thought, to be septicanvc, but the tube inoculated with the blood of the patient remained sterile ; the temperature came down, and the general condition of the patient improved with localisa- tion and amelioration of the local lesions. So probably the carbuncless in the different parts of the body were due to ant's infection or simultaneous infection.

Case V.?Priyanatb, Hindu male, aged 30, clerk by occupation, resident of Howrah. Patient was seen outside, bo the clinical and bacterio-

ogical history of the case is not complete.

On 31st March 1903, the patient came to me with a pimple on the right forearm which he said was very itchy, painful and tender. He had slight fever, but he was not at all worse for the complaint, and he attended to his work as usual. He was given an ordi- nary fever mixture to take, and an icthyol belladonna ointment for application. The next day the patient had high fever, and the pimple had increased into a big inflammatory swelling about 1} inches in diameter, very dark and tender, from which red areola spread for an inch all round At the site of the pimple was a dirty greyish slouch. The axillary glands were slightly enlarged and were tender No track of lymphangitis could be noticed between the carbuncle and the gland. Being suspicious, I took a smear from the sloughs and the pus from a vesicle The slide on examination showed numerous

plague' bacilli, and the slide from the slough, showed some diplococci in addition.

I failed to make any culture as I could not procure the agar tubes. The same treatment continued with some stimulants

and an ordinary surgical dressing instead of the bella- donna ointment.

. The slough gradually separated ; fever subsided gra- dually by a week, the wound healed by a fortuight more.

Case VI. Uamlal, H. M., 30, resident of Cal- cutta, admitted 25th May 1904- discharged 16th June 1904. Admission temperature, 103 *. 0,-al

-.aw-d^red"yp?3U MSpeech and gait not at a? affected. Complained of some cough. On examination of the lungs, at the base of the right

lung over a small area a few crepitant rales were audible; the breathing was also like tubular (rather bronchial). No definite dullness or any other abnor- mality could be made out. On the upper part of the left forearm, there was a

number of small purulent blebs on an inflamed area-one was central and rather large the others were of similar character-smaller and peripherally situated-all were entire. The inflamed area was hard and brawny about 2" in diameter. There was much burning pain in the carbuncle and it was tender. No glands could be detected to be enlarged.

Previous History.-IU for four or five days with fever The carbuncle started the day previous to the onset of fever as a papule which was very itchy_ The next day a boil formed and he got the fever The inflammation spread and in the course of these three days other boils made their appearance. cough he had got only the day before admission. 25th May, 1904.?Temperature 104?F. The boils were

opened and the purulent contents let out Each of the boils showed a greyish yellow slough at the base. The pus was examined bacterio ogica y.

26<A May, 1904.-Temperature between 102* and 103?F. General condition same. No stool. No delirium The carbuncle extending a little more. Dressings soaked with sanguineo purulent discharge The condition of the patient gradually improved. 1 lie carbuncle gradu- ally subsided, sloughs separated and the wound healed vei-v slowlv The lung cleared up in a week's time. He was discharged cured uii 16th June 1904 with a small ulcer.

.

Bacteriological examination ?The sputum was exa- mined No plague bacillus was tound. No pneumo-coccus could be detected. Examination of the bleb contents and the sloughs showed plague bacilli in the slides. Pure culture was obtained in agar tubes and the con- firmatory stalactite growth was also obtained. The lung affection was therefore not specific but accidental.

Case VII. Yam Narayan Swamy, Hindu male, aged fiO hntler bv occupation, resident of 31, Free School Street. Admitted 10th April, 1904. Discharged 15th June, 1904.

U THE INDIAN MEDICAL GAZETTE [Feb., 1907.

Ou admission fever 103?F., speech and gait affected. Pulse soft and frequent. Tongue coated white, semi-con- scious, slightly delirious.

Locally below the right ankle a big red area with some blebs at the centre, one of them was large and central. Plague bacilli only were found in the cultures from the bleb contents and the sloughs.. Slides pre-

pared directly from the sloughs showed plague bacilli only. The femoral glands were enlarged and tender.

Previous History.?Feverish for last four days, only the day before admission he had high fever. The

carbuncle he had for four or five days. 11*A April, 1904.?The blebs all burst. Sloughs could

be seen at their bases. Was delirious at night and had to be tied up, showed a peculiar shaking of the hands. Temperature remained between 102? and 101?

12th April, 1904.?Temperature, 103?102?. The carbuncle was incised and some sloughs removed. The discharge and the sloughs were examined bacte-

riologically and proved to be pure cultures of plague bacilli. Femoral glands less tender but swelling same ?is before. For the next two days, general condition im- proved, temperature came down to 100?F. Seemed to be

always drowsy and the breathing was hurried though the lungs seemed to be quite normal on physical examination.

Drowsiness and some defect of speech continued till 17th April 1904. The sloughs separated from the car-

buncles. Temperature became normal on 18th April, 1904. On 23rd April 1904, a fresh pustule appeared near the cavity of the carbuncle which was now quite red and

healthy and J inch deep. Cn 24th April 1904, the

femoral glands were found fluctuating and were incised, He remained in the plague ward 2 weeks more and

was discharged on 15th June 1904. The carbuncle healed

very slowly.

The following points present themselves for consideration.

1. (a) Whether the carbuncles described

above are ordinary carbuncles caused

by some septic micro-oganisms?the carbuncles appearing independently of the onset of plague, or

(6) They are caused solely b}7 the plague bacilli themselves.

2. If the carbuncles are caused by the

plague bacilli. (a) Whether they are secondary to general

infection occurring through some

other channel, or (b) They merely represent the portals of

infection, or (c) They are the primary and principal

lesions localising the infection. The smear preparations from the unbroken

vesicles failed to show the presence of any septic cocci in all the cases. The culture tubes inocu-

lated from the intact vesicles showed pure culture of plague bacilli. It was only where the vesicles were broken and the smears taken from the open sloughs that the presence of staphylococci was evident (case No. Ill) as well as some diplococci (case No. V). Tube cultures from sloughs showed the presence

of staphylococci in case No. HI where the tube was inoculated from the open sloughs. The

staphylococci after separation were found to be non-pathogenic to guinea-pig.

It is evident therefore that the presence of the

septic cocci was due to secondary infection from outside, access being gained by the open sore.

Hence by exclusion and from the fact that

pure uncontaminated cultures of plague bacilli were obtained from the intact vesicles in all the cases, it is evident that the carbuncles were caused by plague bacilli. The carbuncles do not appear to be secondary to

infection from other sources,for in all the cases the carbuncles appeared before any other trouble mani- fested itself, there was no evidence of the organs like the lungs, etc., being affected, nor was there any grave septicemic symptom in any of the cases. On the other hand all the cases took a rather mild course, and most of them recovered.

Moreover, the tubes inoculated from the blood of the patients remained sterile ; there was a

distinct interval between the appearance of the carbuncles and the affection of the glands. The

glands that showed any affection in these cases were only those which were in direct anatomi- cal relation with the carbuncles.

So it follows that the carbuncles were not

secondary manifestations to a general infection. But it ma}* be said that though no general

infection occurred in these cases, the affection of the glands is the chief localising and reacting lesion, the carbuncles merely representing the

points of entrance of the bacilli like the preli- minary skin lesions ; the pustules, phlyctenea, etc., described by Lowson, Condon, Gaffkey, Wys- sokowitz and Zabolotny, Schottelius, Muller, Ishigan, Simond and Calmette.

Lowson, for example, describes the seat of infection as a patch of red flake as occurs after insect bite without any skin lesion, and also carbuncle-like pustules with tracks of lymphangitis passing from the carbun- cles to the infected gland ; as an illustration, lie gives the case of Prof. Ayoma, who punctured his hand in a

post-mortem examination, and had no reaction at the seat of puncture save a small vesicle, but had a track of lymphangitis up to the affected gland.

Schottelius also gives two cases of infection through wounds with a little inflammation of the edges, and

lymphangitis starting therefrom. Simond also describes the phlyctenea in detail and

distinguishes two varieties : one he calls the "early phlyctenea" coming on at the commencement of the illness which marks the point of penetration of tlie

microbes; and the other "pemphigoid or late phlyc- tenea" which are only accidents of convalescence. The former, he says, are shown by a person infected with plague, and their dimensions are from the size of a pinhead to that of a lentil ?at the circumference there is just a faint reddish tinge, and generally there is no inflammatory reaction. I11 some of these, though very rarely, the phlyctenea, after bursting, leads to

gangrene which may extend in depth and breadth and

produce the so-called pestilential carbuncles which have occasionally brought to the disease the name of "Black

Death," and recovery is exceptional when it goes up to gangrene.

Wyssokowitz and Zabolotny describe simple pustules with lymphangitis between them and the glands.

Gaflky adds to the above certain carhuncular lesioiiB as portals of general infection, but he specifies the occurrence of lymphangitis.

Feb., 1907.] THE PATHOLOGY OF CARBUNCULAll PLAGUE. 45

Felix Simon notes that in two only of the thirteen

cases recorded, of accidental inoculation during tlie

performance of jiost-movtem, <i small vesicle appeared,

but without any inflammatory reaction in the skin.

Condon recordod only four cases in which the point

of infection was represented by a papule with a tiny

vesicle at its summit find without any vital reaction,

although in every case the skin was examined very

carefully. Ishigan describes the case

of a policeman who got

infected through a sore between the toes, and there was

inflammation of the lymphatic radicles.

Thus it appears that in the cases quoted above

tlie skin always failed to react to the infection,

while, on the other hand, the lymphatics invari-

ably responded to the invasion, or general infec-

tion followed and glands enlarged in different

sites, and not merely those that are in direct

anatomical relation with the skin lesion [as de-

scribed by Simond ; and also by Calmette in the

case of R. G. DeSilva at Opporto who had rapid necrosis of the skin in 24

hours in the hand from

the bug bite, followed by the inflammation of the

axillary, cervical and inguinal glands the same

day and by death two days later]. In the cases we have recorded we find that:?

(1) At the cutaneous lesion the plague bacilli

were found to proliferate bringing about a defi- nite reaction of the skin in the form of localised

carbuncle, but there was no rapid necrosis of the

skin.

(2) The affection of the glands when it took

place was not simultaneous and was of those onty

that were anatomically related to the area of the

skin affected; whereas in the cases mentioned

by the authors quoted above there was hardly any interval between

the skin lesions and the

inflammation of the glands "which were in all

cases not only those in anatomical relation with

the parts affected but also those in other parts of

the body. (3) There was no lymphangitis to.show a

primary reaction on the part of the lymphatics

simultaneously with the cutaneous affection. So that it may be taken as proved that in

the cases recorded above the carbuncles were not

merely the points of entrance of plague bacilli,

and that the lymphatic system was not primari- ly affected as shown by

absence of any reaction.

Next we have to consider the frequency of

such cases. Carbuncles have been described as

associated symptoms, sometimes diagnostic and sometimes of much prognostic value since the

time of Thucydides. But these carbuncles were

almost always secondary coming on in the course

of the disease. We can safely set aside the de-

scription of the epidemics before the discovery oi

plague bacillus because many of the epidemics

have been considered not to be plague at all.

Yet a few cases have been recorded which had

typical carbuncles and 110 other disturbance,

among which the case treated by Dr. Goville

may be quoted. Dr. Goville examined a man with

a carbuncle at Constantinople at the early part of the 19th centuiy, This patient had no other

disturbance, ancl Dr. Goville devoloped the disease the next day and succumbed. Coming to more recent times since the discovery of plague bacil- lus we find the mention of the cellulo-cutaneous manifestations, but their occurrence is not so

frequent as in olden times. These cutaneous manifestations have been de-

scribed either as preliminary skin lesions, merely indicating the point of infection or as secondary symptoms. A small number of cases have been recorded, in which there was primary proliferation of

plague bacilli in the skin with secondary infection of glands and of the system in some of the cases. Tucker describes such cases under the name of cellulo-cutaneous type of plague and says that they are characterised by the appearance of the so-called carbuncles, but he is of opinion that they have special features of tlieir own, distinct from the true carbuncles, as they begin as blisters in the turbid serum of which plague bacilli abound, which give way and produce extensive neci'osis of the skin.

Choksey describes such cases as acute necrosis of the skiii starting from a blister winch resembles exactly a small-pox pock. This blister ruptures, leaving a raw angry-looking base which soon becomes dark and cold to the touch and almost, leathery ; the tissues around it are livid and dark, the central necrosis spreads and large areas may become involved. In favourable cases a line of demarcation forms limiting the gangrene and the skin around may show minute epidermal vesicles. He is of opinion that the appearance could not arouse the idea 0 carbuncles. Gordon-Tucker also says that in a very small number of cases the infection might be localised m the skin, but he never noted carbuncles. Strumpell also mentions the "so-called carbuncles"

which come on during the course of the disease, and lie arrees with Choksey ; they are dry or moist gangrene of the skin starting in the pustules and may extend m depth and superficially. Zabolotny notes a case in Mongolia in which on the

surface of the skin a small limpid vesicle appeared, the surrounding skin became red and hard In 24 hours tbo vesicle became opaque, and the contents under the microscope showed plague bacilli ; the vehicle was 1 enlaced by black scab two days later. He does not give a detailed description of the local condition and of further progress of the case.

Schottelius noticed two cases which he describes as ? laree vaccine pock-like pustule with a central scab, very tense and full of clear serum-epidermis not broken. Peripheral to these were similar

_ blisters with opaque

serum and all surrounded by intense red edge. The scab then fall off and the fluid was found a pure culture of plague bacilli." The local condition resembles the lesions of the casea described by me, but a detailed history of the cases is wanting. Both Zabolotny and Schottelius noted that they never

came across such a case in India A greater local resemblance is shown by Dr Ch.lde s case which had a true carbuncle. But the case came very late when the whole swelling had no skin on it with a history that somr indigenous ointment was applied after which it increased;0 glands in different parts were affected ; the discharge from the carbuncle was not examined bac- teriologically.

So we see that these cases are very rare?only three cases quoted above being all that I could find in recent literature.

46 THE INDIAN MEDICAL GAZETTE. [Feb., 1907.

Let us now explain the cause of rare occur-

rence of these cases.

Plague is a septicsemic disease according to Dr. Bitter. He observes that in rats it always produces septicsemia without any local reaction even when the conjunctiva is smeared with a culture of plague bacilli. This is due to the animal's extreme susceptibility. In man who, according to Bitter, is less susceptible than rat, it is also septiceemic, with the peculiarity that a local reaction caused by the invasion of the

plague bacillus is produced in the lymphatic glands corresponding to the site of inoculation, but none at the latter point. Hankin experimented on animals and found

horses, cattle, sheep and goats more refractory in the order in which they are mentioned here. In the cow, according to him and the German Com- mission, local abscess formed, but the pus was found sterile showing the destruction of the

plague bacilli by the tissue cells. In sheep locally an abscess, with plague bacilli containing pus, formed?the animal recovering after slight fever. These facts show that local reaction

depends much on the resistance of the skin of the animals inoculated.

Another fact, which is generally observed, is that during the middle and end of an epidemic the virulence of the bacilli is diminished as

shown by the generally mild character of the cases. The cases noted above occurred during the month of March or later when plague in Calcutta is on the decline.

Conclusion.

(1) Carbuncles can be caused by plague bacilli without the help or intervention of any other

micro-organism. (2) Such cases of carbuncle have been ob-

served, though their number is small; (3) They can be the primary and chief mani-

festation of the affection ; and

(4) Tliey may be classed separately. In conclusion, I should express my heartfelt

thanks to the authorities of the Medical College Hospital for having kindly allowed me to use the ca^-notes of the patients for the purpose of my/paper.