x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague O51 
tonsillar bubo’’ has been introduced to designate the lesion oc- 
curring in the tonsil when that organ forms the portal of 
entrance of the bacillus to the organism, and it appears that 
such “tonsillar buboes” are associated with primary buboes of 
the second order in the prevertebral glands, whereas primary 
buboes of the parotid or submaxillary lymphatic glands are not 
associated with tonsillar lesions. 
It appears of importance to emphasize the occurrence of pha- 
ryngeal lesions in cases without pulmonary involvement, since 
these, as well as the pulmonary cases, may have infective sputum. 
The more thorough the study of bubonic plague, the greater 
appears the number of methods of possible direct and indirect 
transmission of the disease. In regard to the other viscera the 
particular features brought out in the present work are the 
relative infrequency of specific focal plague lesions except in the 
skin and the relative frequency of that lesion of the kidneys to - 
which Herzog especially directed attention: namely, fibrin throm- 
bosis of the glomerular capillaries, which was present in at 
least 41 per cent of my cases. Two notable cases of plague 
meningitis have also been encountered in this series. 
SOURCE AND CHARACTER OF MATERIAL 
Bubonic plague appeared in Manila in June, 1912, 89 cases 
occurring up to June 13, 1914. In rats the disease is known 
to have been present since August 31, 1912, and 49 plague- 
infected rats were found up to June 13, 1914. Seventy-five of 
the human cases proved fatal, and post-mortem examination of. 
all of these cases was made. 
All fatal cases were autopsied at periods varying from a 
short time to two or three days after death; two of them were 
performed after extensive putrefactive changes had taken place, 
the bodies having been previously buried. In all except these 
two cases the bodies were in a good state of preservation. The 
anatomic diagnosis was always confirmed by smears, cultures, 
agglutination of cultures, or by guinea-pig inoculations of por- 
tions of tissue removed from various parts of the body. In 
all of the earlier cases the bacteriological investigation included 
all four of the above procedures, as was also true in the later 
cases in which there was any possibility of doubt as to diagnosis. 
The tissues selected for routine bacteriological examination were 
from the buboes and spleen. 
Mortality —Up to June 13, 1914, 89 cases occurred in Manila, 
75 of which were fatal. The mortality was, therefore, 84.27 
per cent. 
