x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 968 
single, and in 2 cases, double. In 1 case the lesion was situated 
in immediate relation to a primary bubo, while in the other cases 
the infection was presumably through the blood. 
Case 2623.—The upper arms and back present numerous small, circular, 
red, slightly elevated foci without suppuration, which measure up to 0.5 
centimeter in diameter. In the left axilla is a large dark area measuring 
1.5 centimeter in diameter, on section into which there is necrosis of the 
skin and immediately underlying tissues, with very dark discoloration as 
though due to hemorrhage. A similar, slightly smaller area is present 
over the manubrium sterni. 
Case 2993.—On the left shoulder over the supraspinous fossa is a rup- 
tured pustule, 0.5 centimeter in diameter. Surrounding this is a circle of 
elevated vesicles, one or two of which have been ruptured. These contain 
reddish serous fluid. Surrounding this is a zone of deep red skin, the 
entire area measuring 4 centimeters in diameter. The underlying tissue 
is firm. Just behind the clavicle to the inner side of the skin lesion are 
two adjacent, softened, hemorrhagic lymphatic glands about 1 centimeter 
in diameter. The tissue surrounding these is cedematous and red with 
numerous hemorrhages. This forms the primary bubo. 
Case 2883.—Over the left buttock just to the left of the lumbosacral 
‘articulation there is a slight excoriation of the skin with a broad zone of 
reddish discoloration about it. On section into this, reddish creamy fluid 
exudes, and there is found extensive softening and reddish discoloration 
of the subcutaneous tissue, extending for a depth of 0.5 centimeter. Over 
the right buttock near the gluteal fold is a smaller and more superficial 
reddish area, section into which shows slight reddish discoloration of the 
tissue only; there is no pus at this point. At other portions of the body 
are seen a few minute, red puncte, these being most numerous over the 
arms. 
HISTOPATHOLOGY OF THE SKIN 
The lesions occurring at the points which were supposed to be 
the portals of entry have been already described. There remain 
the hemorrhages, papules, and carbuncles. The hemorrhagic 
lesions consist of simple hemorrhages in the corium and sub- 
cutaneous tissue. This hemorrhage is small and does not often 
extend into the epithelial layer. In my cases there were no 
large diffuse cutaneous hemorrhages such as have been described 
in some epidemics. It was these large cutaneous hemorrhages 
that caused the disease to be described as the “black death.” 
The papules present a very characteristic picture of necrosis of 
the skin with leucocytes and bacterial invasion. A detailed des- 
cription of one of the papules from case 2335 is here given. 
Case 2385.—At the point of the lesion the skin is slightly elevated on 
account of the infiltration to be described. The epidermis at the apex is 
reduced to about one quarter of its normal thickness, and all traces of epi- 
dermal layers have been destroyed. Here the papille are lacking, and 
the epidermis is represented by an almost homogeneous eosinophilic mass 
with very few nuclei visible. Clefts in this epidermis show masses of 
