x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 961 
lesion was visible in the area drained by the glands forming the 
primary bubo which could be designated as the portal of entry. 
In a few cases small papules looking like insect bites were found, 
which in sections showed some necrosis of the skin and masses 
of bacilli, but it cannot be denied that these might have been 
noninfective bites which formed a locus minor resistentiz, which 
favored infection through the blood stream. 
Castellani and Chalmers state :5 
The site of inoculation is sometimes marked by a vesicle, the contents 
of which contain the Bacillus pestis in considerable numbers. 
Albrecht and Ghon state: 
In no single case could we demonstrate with absolute certainty and 
incontestably the immediate portal of entry of the pest virus. 
The skin is a frequent seat of secondary plague lesions, and 
plague bacilli may also contaminate wounds and abrasions of 
the skin. Therefore the presence of pest bacilli in a cutaneous 
lesion, even though the infection occur in the area of skin drained 
by the glands constituting the primary bubo, is not sufficient 
evidence to class that lesion as indubitably the primary portal 
of entry. 
The mucous membranes that form portals of entry are those 
lining the nose, mouth, pharynx, conjunctiva, and the genitalia. 
The tonsils are a frequent portal of entry in cases of cervical 
buboes. (See discussion under cervical buboes.) 
In 2 of our cases (1969, 2084) there were found lesions on the 
foot which, judging especially from the histologic appearance, 
were in all probability primary lesions. The lesion appears to 
extend, in these cases, from the skin into the subcutaneous 
tissues, and is characterized by congestion, cedema, necrosis, 
hemorrhage, masses of bacteria, leucocytes, and swelling of the 
endothelial cells. One of these cases will be described in greater 
detail. 
Case 2084.—Over the middle of the fifth left metatarsal bone is a small, 
pale papule, or blister, of the skin. Section of this shows it to contain 
a small amount of turbid fluid. This case has a left femoral bubo and 
cutaneous petechiz. Microscopic section of the papule shows some cedema 
of the epithelium and corium. In the corium and subjacent tissue the 
fibers of connective tissue are separated (cedema). The vessels are dis- 
tended with blood. There are large zodgleal masses of bacteria between 
the tissue fibers, about the sweat glands, and in the lymphatic vessels. 
** Manual of Tropical Medicine. Wm. Wood & Co., New York (1910), 
783. 
* Uber die Beulenpest in Bombay im Jahre 1897. Wien (1898), II B, 
484. 
