x,p,4 Crowell: Pathologic Anatomy of Bubonic Plague 275 
and sometimes softened. The hemorrhage and cedema about 
these glands are generally not so marked as about the glands 
forming the primary bubo of the first order; but the hemorrhage 
and cedema about the ureter and lower pole of the kidney of the 
affected side may be very extensive. The involvement of the 
glands may extend upward along the vertebral column, affecting 
all the lumbar glands as far up as the cceliac axis, and may extend 
across the vertebrz, involving the glands of the opposite side. 
The peritoneum overlying these glands may show punctate, or 
larger, more diffuse hemorrhages. Frequently the serous sur- 
face of the sigmoid flexure of the colon lies in apposition with the 
peritoneum covering the iliac glands and becomes the seat of 
an extensive hemorrhagic condition. Retrograde metastases 
may occur along the lymph channels to the groin opposite the 
original bubo, and the glands here may show changes similar 
to those of primary buboes of the second order. The glands” 
of the opposite side may also be infected secondarily through the 
blood stream. 
The Anglo-Indian Commission maintains that the type leading 
to early septicemia is that in which the glands forming the 
primary bubo of the first order show very little enlargement 
and but little intra- or extraglandular hemorrhage or cedema. 
In this instance the bacilli are said not to be held back by the 
lymphatic glands. Cases have been encountered in my series 
in which the femoral and inguinal glands showed slight or no 
changes, while the iliac glands showed the changes usual in 
primary buboes of the second order. Those cases in which no 
changes were recognizable in the femoral or inguinal glands will 
be referred to under the heading of “‘iliac buboes.”’ 
The Austrian Commission demonstrates that true suppuration 
may occur in the primary bubo from the action of the plague 
bacillus. In my series are instances of suppuration in the pri- 
mary bubo and in the meninges in which the plague bacillus only 
was demonstrable. Abstracts of the records of these. cases 
follow. 
CASES OF SUPPURATION OF BUBOES 
Case 2086.—Filipino, male, 37 years old. The duration of illness was 
seven days. This was anatomically a typical uncomplicated case of bubonic 
plague with a right femoral primary bubo. The description of the bubo is 
as follows: The right femoral region shows slight bulging. On section over 
this region a large cedematous mass is disclosed, which includes one large 
and several small lymphatic glands. The largest is about 3.5 centimeters 
in diameter, reddish gray, and very soft and necrotic. The smaller glands 
are red and hemorrhagic, but not much softened. There is very little 
