262 The Philippine Journal of Science 1915 
A few polymorphonuclear leucocytes are present. There is a small hem- 
orrhagic extravasation in the outer portion of the corium and some 
necrosis of tissue about this. Nuclear fragments are seen scattered through- 
out the area. The area of involvement is greater in the subcutaneous 
tissue than in the epidermis; the bacteria are very numerous and are 
present throughout the entire lesion. The endothelial cells lining the lym- 
phatics are large and prominent. While this picture does not furnish 
absolute evidence of primary cutaneous infection, neither does it exclude 
it, and taken with the other findings in the case, it is considered that this 
is in all probability the portal of entry. 
SKIN 
The Austrian Commission ”° states that the most frequent 
alteration in the skin is the occurrence of multiple hemorrhages, 
varying in size from 2 millimeters to several centimeters in 
diameter. These are embolic in nature, the vessel lumen being 
occluded by a bacterial embolus, and they are most frequent in 
cases with abundant bacteria in the blood and spleen. That 
they are not purely toxic in origin is shown by the fact that 
when only a few or no bacilli are in the circulation these hem- 
orrhages are scant or absent. 
In my cases hemorrhages in the skin were not noted as of 
unusually frequent occurrence, and they were often so small 
as to escape notice after death, unless attention was drawn to 
them by the physician who had seen the case during life. Small 
vesiculopapular lesions were present in at least 8 of my cases, 
in some being numerous and widespread over the body and in 
others being localized. The most frequent type is one in which 
there are small pinhead-sized, conical, pearly nodules surrounded 
by a hyperemic zone. Incision into these discloses a turbid fluid 
which contains plague bacilli in greater or lesser numbers. 
Plague carbuncles occasionally occur. These are described by 
the Austrian Commission as circular, prominent areas, up to 8 
centimeters in diameter, with elevated, firmly infiltrated mar- 
gins. In the center the epithelium is raised as in a blister, 
which is filled with thick, reddish exudate. If the blister bursts, 
the contents, with many bacilli, flow out and the dried-up epithe- 
lium collapses and lays bare a moist, damp, bright red and yellow 
spotted and speckled corium forming the base of the ulcer. 
These may develop from direct extension over a bubo, by in- 
fection through the lymph stream, or through the blood stream. 
In 5 cases there were lesions of the skin which corresponded 
more or less closely to the description of the plague carbuncle 
furnished by the Austrian Commission. In 8 cases these were 
* Uber die Beulenpest in Bombay (1898), II B, 481. 
