x, B,4 Crowell: Pathologic Anatomy of Bubonic Plague 257 
Schobl * made blood cultures from patients with bubonic plague 
at periods of from three and one-half to seventy-five and one- 
half hours before death. He concludes that: 
(1) A severe septicemia may be present at a comparatively early stage 
of the disease and for a considerable number of hours before death, and 
(2) the septicemia may be of an irregular and fluctuating type. 
Further he states: 
(1) * * * that positive blood culture was obtained in practically 
every case that was examined in the febrile stage of the disease, even 
when buboes or signs of pulmonary involvement had not been detected 
clinically. (2) It is evident that Bacillus pestis may be found in the circu- 
lating blood of the patients even in cases which subsequently recover. 
In the evidence concerning the occurrence of septicemic plague 
above quoted, there appears much that is indefinite and some 
that is conflicting. Hence it is not surprising that there is some 
confusion as to exactly what constitutes a case of “septiceemic 
plague,” if, indeed, such a category is necessary in the nomen- 
clature of plague. Strictly speaking, any case of plague in 
which the organisms multiply in the circulating blood is a case 
of septicemic plague, but the adoption of this standard would 
place all fatal cases of both primary bubonic and primary 
pheumonic plague in this category. Therefore it would seem 
more rational to include in this class only those cases (1) in 
which septiczemia is evidently an early event (2), those in which 
gross focal visceral plague lesions occur, and (3) those in which 
the primary buboes are not prominent. These cases are the ones 
which give rise to the greatest difficulty from the clinical stand- 
point, which fall naturally into a class by themselves in the 
mind of the clinician, and which present both clinically and 
anatomically the most unmistakable evidences of septicemia or 
septicopyemia. 
All three of these features may not be present in the same 
case, and therefore all cases in this class may not be of exactly 
the same type anatomically. 
In this class should also be placed those cases in which there 
is mixed infection; that is to say, those in which more than one 
variety of organism can be isolated from the spleen after death. 
INTESTINAL PLAGUE 
Some writers have considered that the gastrointestinal tract 
may be the portal of entry of the plague bacillus and have dis- 
“This Journal, Sec. B (1918), 8, 418, 415. 
