x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 269 
may be summarized somewhat as follows: First, there is mul- 
tiplication of bacilli; then follow congestion, cedema, ‘“catarrh”’ 
of the lymph sinuses, hyaline degeneration and necrosis of the 
walls, migration of erythrocytes and leucocytes, necrosis of 
glandular tissue, hemorrhage, formation of fibrin in and about 
the vessels, vascular thrombosis, and similar involvement in 
the capsule of the gland and the periglandular structures. These 
changes are essentially those of hemorrhagic (occasionally sup- 
purative) inflammation, with coagulation necrosis. The chief 
peculiarity of the plague bubo is the very abundant cedema of 
the periglandular structures. The lesions that have been de- 
scribed occur in varying grades of intensity and in varying 
combinations in all plague-infected glands. In some the hzemor- 
rhage and cedema may be the most-marked feature, while in 
others suppuration. may occur. In slightly affected glands the 
changes may consist only of bacterial multiplication, cedema, 
congestion, and catarrh of the sinuses. These form the most 
prominent features in the average secondary bubo, although 
in some of these there may be slight hemorrhage and slight 
necrosis. The involvement of the capsule and the periglandular 
tissue is usually minimal or absent in secondary buboes. 
BUBONIC PLAGUE WITH EARLY SEPTICA7MIA (SO-CALLED SEPTIC4=MIC PLAGUE) 
The literature on septicemic plague has been quoted rather 
fully in the intreduction. The evidence as to what exactly 
constitutes a case of septicemic plague is rather confusing. 
Strictly speaking, any case of plague in which the organisms 
multiply in the circulating blood is a case of septiczemic plague, 
but the adoption of this standard would place all fatal cases 
of both primary bubonic and primary pneumonic plague in this 
category. It would, therefore, seem more rational to include 
in this class only those cases in which septiceemia is evidently 
an early event, those in which gross focal visceral plague lesions 
occur, and those in which the primary buboes are not prominent. 
These cases are the ones which give rise to the greatest difficulty 
from the clinical standpoint, 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. 
